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The purpose of this article is to review the surgical management and outcome of toxic megacolon and to update the aetiology of toxic megacolon.A retrospective chart review of three academic colorectal surgery units was undertaken. Over a period of 20 years, 70 patients with surgically managed toxic megacolon were identified: 32 men and 38 women, median age 63 years (range, 23–87 years).In 33 (48%) patients the main cause of toxic megacolon was inflammatory bowel disease. Thirty-seven (52%) patients had toxic megacolon of different aetiology. Sixty-three patients underwent colonic resection: 49 (70%) subtotal colectomies and 14 (20%) total colectomies, including 4 (6%) proctocolectomies. Seven (10%) patients had decompression (n = 3) or faecal diversion (n = 4) only. Forty-four of the resected patients underwent a Hartmann's procedure and an ileostomy; 13 (19%) patients had primary anastomoses, 11 (16%) ileorectal anastomoses (IRA) and 2 (3%) patients had ileal pouch-anal anastomosis (IPAA). Twenty-six (37%) patients subsequently had continuity restored. Total surgical complication rate was 19% (n = 13), 8% (n = 4) in patients treated with subtotal colectomy, 21% (n = 3) in patients treated with total proctocolectomy and 86% (n = 6) in patients treated with either decompression or diversion. The total mortality rate was 16% (n = 11).Toxic colitis complicated by toxic megacolon can occur after various diseases of the colon and remains a life-threatening disorder associated with a significant risk of postoperative complications. Subtotal colectomy with ileostomy remains the procedure of choice. Surgical colonic decompression with faecal diversion alone is associated with a high rate of complications.