Restorative proctocolectomy with IPAA is now accepted as the standard of care in most patients with a diagnosis of mucosal ulcerative or IndC requiring surgery. In patients with Crohn's colitis needing intervention, proctocolectomy with end ileostomy or subtotal colectomy with ileorectal anastomosis is still the treatment of choice. In the authors' institution they consider performing an ileal pouch for a diagnosis of Crohn's colitis requiring rectal resection provided there is no existing or previous evidence of perianal or small bowel CD. They only perform this in a well-motivated patient who understands the potential sequelae, including an increased incidence of adverse effects and reduced functional outcome, if they develop CD of the pouch. A significant amount of time must be allocated to the patient and their family when counseling them with regards to the potential surgical options and outcomes associated with each. The development of CD of the pouch is associated with a considerable pouch failure rate requiring pouch excision or indefinite ileostomy formation. It does not always herald disaster, however, and a large percentage of patients can be salvaged using a combination of medical and surgical therapy. In this patient group the maintenance of intestinal continuity and avoidance of an ostomy is often the most important factor in their perception toward quality of life. The search for a serologic or genetic marker that will predict disease outcome in this select patient group and thereby direct surgical decision making should continue. It is recommended that in the presence of Crohn's colitis the decision to perform an ileal pouch should only be made in a tertiary center under the care of gastroenterologists, histopathologists, and colorectal surgeons with experience in the management of these complex cases.