We reviewed the records of 51 patients over 65 years of age admitted for an initial episode of sigmoid volvulus, and adequate information about their subsequent course was obtained in 92 percent. Nonoperative reduction of the initial volvulus was attempted in 43 patients and was successful in 39 (91 percent). Eleven patients required emergency operations, with a mortality rate of 36 percent. Six patients had elective resections with no deaths. Thirty-three patients, 32 after nonoperative reduction of a volvulus and 1 after operative reduction, were discharged without definitive treatment. Twenty-three of the 33 patients (70 percent) managed by expectant observation had one or more episodes of recurrent volvulus. Five of the 23 patients died from the recurrence without operation, and 16 were operated on either emergently (3 patients) or electively (13 patients) after nonoperative reduction. The mortality rate related to recurrent volvulus or its treatment in the 33 patients observed was 21 percent. The mortality rate for 18 elective resections (6 for initial volvulus and 12 for recurrent volvulus) was 5.6 percent. After successful nonoperative reduction of a sigmoid volvulus in elderly patients, maximal survival is achieved by early elective resection. Age alone is not an adequate reason for adopting a nonoperative approach.