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Surgical strategy for perianal Crohn's: Lessons from TOpCLASS

MRI-guided staging helps reshape surgical decision-making.

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A dynamic, MRI-based classification system can guide staged surgical decision-making in fistulizing perianal Crohn’s disease, with most patients moving between disease classes over time and many benefiting from coordinated medical and surgical optimization.
 
During the 2026 Crohn’s & Colitis Congress®, a partnership of AGA and the Crohn’s & Colitis Foundation, held in Las Vegas, Stefan D. Holubar, MD, professor of surgery at the Cleveland Clinic Lerner College of Medicine, highlighted findings from the TOpCLASS consortium, which categorizes perianal Crohn’s disease by anatomy, inflammation, and tissue damage to support treatment selection.
 
In a real-world application of the classification in a serial fistula MRI cohort, class II disease — characterized by active fistulas requiring drainage and inflammation control — was the most common subtype, accounting for 78% of patients. More than half of patients changed class during follow-up, underscoring what Dr. Holubar called the “dynamic nature” of fistulizing disease.
 
MRI played a central role in both classification and outcome assessment. Sankey diagram analyses showed frequent upward migration, particularly from Class IIB (complex fistulas requiring seton drainage) to Class IIA, in which definitive repair becomes feasible. Dr. Holubar emphasized that clinical closure alone is insufficient, citing prior evidence that MRI-confirmed healing is required to define success. MRI was used selectively but liberally in complex, recurrent, or nonhealing cases, and routinely before and after attempted repair.
 
In Dr. Holubar’s experience, management of Class II disease follows a stepwise paradigm. The priority is sepsis control through what he termed “surgical rationalization,” including saturation drainage with setons, Penrose drains, and/or mushroom catheters in all tracts, followed by staged simplification over serial examinations under anesthesia. In parallel, inflammation is addressed through optimization of advanced medical therapies in collaboration with gastroenterology. Only after both sepsis and inflammation are controlled is definitive repair attempted. “Surgeons do not operate in isolation,” he added. “Collaboration with IBD specialists and gastroenterologists is essential.”
 
According to Dr. Holubar, fistulotomy shows high success in carefully selected patients with low tracts and minimal sphincter involvement, with a small risk of minor continence changes. Curettage and closure, a novel operation first described in the ADMIRE-II study as an active placebo, is a sphincter-sparing approach without stem cells, and achieves approximately 50% success. The procedure has been described as low risk and repeatable. Endorectal advancement flaps remain the “workhorse” repair, he said, with reported success rates of roughly 50% to 70%, albeit with some minor continence alternations.
 
For patients with Class IIC disease marked by tissue destruction and impaired quality of life, fecal diversion is often required. Dr. Holubar cited updated meta-analytic data indicating that about 80% of diverting ileostomies placed for perianal Crohn’s ultimately become permanent, a point he said should be discussed explicitly with patients. In refractory cases progressing to Class III disease, intersphincteric proctectomy is offered, preserving the external sphincter to improve wound outcomes and quality of life.
 
Even after proctectomy, healing is incomplete in a substantial minority of patients. After intersphincteric proctectomy, only about 70% of patients achieved complete perineal healing at one year, leaving some with persistent drainage classified as Class IV disease. In a published case he cited from 2022, management included early recognition, aggressive wound care, negative-pressure therapy, hyperbaric oxygen, biologic optimization, and selective plastic surgical closure.
 
Dr. Holubar emphasized that perianal Crohn’s disease affects roughly 25% of patients and that treatment goals should prioritize a “dry, pain-free bottom,” even when that requires diversion or resection. He also called for more randomized trials and highlighted ongoing studies within the TOpCLASS consortium to strengthen the evidence base.
 
Dr. Holubar disclosed that he has received grants from the American Society of Colon & Rectal Surgeons and the Crohn’s & Colitis Foundation.

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