AIM: To evaluate outcome and morbidity following major surgical interventions for inflammatory bowel disease. METHODS: Retrospective case note analysis of 227 children admitted to a tertiary referral centre between 1994 and 2002 for treatment of inflammatory bowel disease. RESULTS: Twenty six out of 125 children with Crohn's disease (21%) required surgical management. Thirteen with disease proximal to the left colon underwent limited segmental resections and primary anastomosis, without significant morbidity. Primary surgery for 13 children with disease distal to the transverse colon included 6 subtotal- or panprocto- colectomies. All 7 children undergoing conservative segmental resections, (3 with primary anastomosis, 4 with stoma formation), required further colonic resection or defunctioning stoma formation. All 3 children undergoing primary anastomosis developed a leak, or fistula formation. Twenty two out of 102 children with ulcerative colitis (22%) required surgery. Definitive procedures (17) included J-pouch ileoanal anastomosis (11), ileorectal anastomosis (2), straight ileoanal anastomosis (3), and proctectomy/ileostomy (1). Five children await restorative surgery following subtotal colectomy. Median daily stool frequency following J-pouch surgery was 5 (range: 3-15), and 10/11 children reported full daytime continence. All 3 children with straight ileoanal anastomosis had unacceptable stool frequency and remain diverted. CONCLUSION: The complication rate following resectional surgery for inflammatory bowel disease was 57% for Crohn's disease, and 31% for ulcerative colitis. In children with Crohn's disease, limited resection with primary anastomosis is safe proximal to the left colon. Where surgery is indicated for disease distal to the transverse colon, subtotal or panproctocolectomy is indicated, and an anastomosis should be avoided. Children with ulcerative colitis had a good functional outcome following J-pouch reconstruction. However, the overall failure rate of attempted reconstructive surgery was 24%, largely due to the poor results of straight ileoanal anastomosis.