Introduction <p>Crohn’s disease is a chronic inflammatory bowel disease (IBD) affecting 1.85–10.5 individuals per 100,000 per year. Approximately 30–50% of patients still require surgery during their lifetime. While patients with Crohn’s disease are at increased risk of postoperative complications, ileocecal resection remains a viable alternative to medical treatment for terminal ileitis. However, the optimal timing for initiating immunosuppressive therapy postoperatively, whether as a prophylactic measure or upon disease recurrence, remains a topic of debate. This study aimed to identify perioperative risk factors for disease recurrence to support a more tailored approach to early postoperative immunosuppressive therapy.</p> Methods <p>A retrospective chart review was conducted on all patients who underwent ileocecal resection for Crohn’s disease between January 2006 and March 2023. The primary endpoint was the need for advanced medical therapy for Crohn’s disease within one year postoperatively. Secondary endpoints included clinical and endoscopic recurrence after one year and time to start advanced medical therapy, clinical recurrence and endoscopic recurrence. The following possible prognostic factors were analysed: age, sex, smoking status, BMI, presence of perianal disease, length of resection, advanced medical therapy, previous resection, previous appendectomy, behaviour classification, and disease extent.</p> Results <p>A total of 129 patients were included, with a median follow-up of 98 months. Higher BMI category was the most robust predictor for advanced medical therapy at one year (OR = 1.88, 95% CI [1.20–2.95], <i>P</i> = .006) and for time to endoscopic recurrence (HR = 1.62, 95% CI [1.21–2.16], <i>P</i> = .001). Previous bowel resection was significantly associated with advanced medical therapy on univariable analysis (OR = 3.25, 95% CI [1.39–7.61], <i>P</i> = .007), with a trend persisting in the multivariable model (OR = 2.49, <i>P</i> = .06). Perianal disease was associated with shorter medication-free survival (HR = 1.64, 95% CI [1.03–2.62], <i>P</i> = .04). Penetrating disease behaviour was linked to earlier start of advanced medical therapy on univariable analysis (HR = 1.60, 95% CI [1.02–2.50], <i>P</i> = .04). Female sex showed a trend toward a protective effect on clinical recurrence (OR = 0.47, <i>P</i> = .08).</p> Conclusion <p>In this cohort, ileocecal resection was associated with substantial symptomatic improvement. To our knowledge, this study is the first to identify increased BMI as an independent risk factor. Furthermore, it suggests that perianal disease may be associated with increased recurrence risk, while female sex may be associated with lower risk. A more contemporary estimate of surgical reintervention after ileocecal resection for Crohn’s disease may be closer to 12% rather than the historically cited 35%, based on long-term follow-up in this cohort.</p>