BACKGROUND Patients with Crohn's disease have a higher failure rate after ileal pouch surgery compared with their counterparts with ulcerative colitis. OBJECTIVE We hypothesized that risk of continent ileostomy failure can be stratified based on the timing of Crohn's disease diagnosis and aimed to assess long-term outcomes. DESIGN This was a retrospective cohort study. SETTINGS The investigation took place in a high-volume, specialized colorectal surgery department. PATIENTS Patients with Crohn's disease who underwent continent ileostomy surgery between 1978 and 2013 were evaluated. MAIN OUTCOME MEASURES Functional outcomes, postoperative complications, requirement of revision surgery, and continent ileostomy failure were analyzed. RESULTS There were 48 patients (14 male patients) with a median age of 33 years at the time of continent ileostomy creation. Crohn's disease diagnosis was before continent ileostomy (intentional) in 15 or made in a delayed fashion at a median 4 years after continent ileostomy in 33 patients. Median follow-up was 19 years (range, 1-33 y) after index continent ileostomy creation. Major and minor revisions were performed in 40 (83%) and 13 patients (27%). Complications were fistula (n = 20), pouchitis (n = 16), valve slippage (n = 15), hernia (n = 9), afferent limb stricture (n = 9), difficult intubation (n = 8), incontinence (n = 7), bowel obstruction (n = 7), valve stricture (n = 5), leakage (n = 4), bleeding (n = 3), and valve prolapse (n = 3). Median Cleveland global quality-of-life score was 0.8. Continent ileostomy failure occurred in 22 patients (46%). Based on Kaplan-Meier estimates, continent ileostomy survival was 48 % (95% CI, 33%-63%) at 20 years. Continent ileostomy failure was similar regardless of timing of diagnosis of Crohn's disease (p = 0.533). LIMITATIONS This study was limited by its retrospective and nonrandomized nature. CONCLUSIONS Outcomes of continent ileostomy in patients with Crohn's disease are poor, regardless of the timing of diagnosis. Very careful consideration should be given by both the surgeon and the patient before undertaking this procedure in patients with Crohn's disease. See Video Abstract at http://links.lww.com/DCR/A327.