With the elderly population rising continuously, surgeons are increasingly confronted by the dilemma of operative management in these patients, which frequently encompasses end-of-life issues. Increasing age and emergent surgery are known risk factors for poor outcomes in colon surgery. The purpose of this study is to delineate differences in outcomes between emergent and elective colon surgery and identify risk factors that can guide the surgeon in caring for the extreme elderly (age 80 years or older). From 2001 to 2006, a retrospective review of the resident database at Greenville Hospital System identified 104 extreme elderly patients who underwent colon surgery (65 elective, 39 emergent). Comparing elective and emergent operations, results showed substantial differences in morbidity (20% vs 51.2%, P < 0.001), 30-day mortality rate (7.7% vs 30.7%, P < 0.005), and length of stay (13.6 days vs 21.6 days, P < 0.004). Percentage of patients discharged to home was significantly less in the emergent group (13% vs 59%, P < 0.001). Evaluation of the emergent surgery group revealed male gender, history of smoking, and ischemic changes on pathologic examination were statistically significant risk factors for failure of surgery. As a result of the high-risk nature of emergent colon operations in the extreme elderly, it is important that surgeons carefully assess the benefits in relation to the risks and functional outcomes of surgery when planning patient care and providing informed consent.