Our Super Specialty: Complex Anal Fistula

Anorectal fistulas are a common and vexing problem that can significantly affect quality of life. When left untreated, patients with the condition can get repeated infections and abscesses. Anyone is at risk of developing the condition, however, they may be associated with other conditions like Crohn’s disease, where fistulas might be more complex, recurrent and particularly difficult to manage.

Surgery is the only option for cure. Different procedures can be used, however success rates are variable regardless of the type of procedure, surgeon performing the operation, the center where it is done, or any specific disease process the patient might have.

The mission of the Complex Anal Fistula Program at the Global Center is to promote healing of all anal fistulas while maintaining as normal anal function as possible.

To make an appointment with the Complex Anal Fistula Program at the Global Center for Integrated Colorectal Surgery & IBD Interventional Endoscopy, please call us at (212) 342-1155.

Care at the Global Center

Our team has developed expertise in the management of these fistulas with a high rate of success.

Dr James Church, who was instrumental in building one of the most reputable colorectal divisions in the world at the Cleveland Clinic over nearly four decades, is the head of the Complex Anal Fistula Program.

A recent study that reviewed Dr Church’s specific results for the management of anal fistulas revealed a success rate of healing of 98% in patients without Crohn’s disease and 87% in those with Crohn’s disease.  The procedure described by Dr. Church is called Obliteration of the Intrasphincteric Tract.

All the surgeons in the Columbia Division of Colorectal Surgeon employ the Obliteration of the Intrasphincteric Tract procedure, using Dr Church’s technique and principles of treatment. They have all been proctored by Dr Church and co-manage patients under his guidance.

Anal Fistula FAQ

How do fistulas happen:

Most anal fistulas happen when an anal mucus gland gets blocked. This causes an infection beside the anus that becomes an abscess. The abscess is drained and between a third to a half of drained abscesses become a fistula.

How do I know I have a fistula:

You will notice pus coming from a hole beside your anus. This is the hole where the abscess popped all by itself or where your doctor drained it with a scalpel or scissors. Sometimes there are more than one hole.

Where does the pus come from?

The opening of the anal gland that becomes infected is about an inch inside the anus. Bacteria get into the gland and cause an infection. The gland opening is connected to the external opening by a track and infection in the track makes pus.

Will the fistula get better?

Not by itself. It will need some sort of surgery.

What needs to be done to get the fistula to heal?

The fistula is fed by bacterial in the rectum getting in to the track and causing an infection there. We need to stop bacteria getting into the track and close the track as it passes through the anal sphincter.

How do you do this?

It depends how deep the fistula goes. If it is just under the skin the fistula can be opened up and allowed to heal by itself. This is a Fistulotomy. It is the most successful way of treating a fistula. Fistulas the go through the sphincter muscle are usually not opened because this would mean cutting the sphincter muscle and this might lead to loss of control of gas or stool.

Deeper fistulas going through the muscle are treated by surgery. There are usually two steps.

1. Put a seton into the track. This is done with the patient asleep. A probe is passed through the external opening to find the internal opening. A seton is then pulled through the track and tied in a circle. This is a soft drain that is well tolerated.
2. After 6 weeks a repair of the fistula can be done. This is more involved. It is illustrated in the pictures. A. The internal opening is cleared. Small flaps are made to expose the muscle of the internal sphincter. B. The internal sphincter is closed with deep stiches. C. The flaps are closed. D. The final result
   

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What are fistulas in Crohn’s disease?

Patients with Crohn’s disease often develop disease near the anus that includes fistulas. Some of the fistulas are similar to those found in any patient and these can be repaired in the same way. Other fistulas occur in the setting of Crohn’s disease in the tissues around the anus. These patients need biologic therapy to control the Crohn’s disease before surgery to repair the fistula. 

Program Highlights

Unmatched Outcomes That Preserve Dignity and Quality of Life

The Global Center has excellent outcomes for patients with the continent ileostomy seeking management of pouch problems. There is a high rate of pouch preservation after both primary pouch creation and revision using a combined medical, interventional endoscopic, and surgical approach. Our patients consistently report a high quality of life post-surgery.

World-Class Minimally Invasive Options

We are the preeminent Center for endoscopy for pouch surveillance, corrective procedures for pouch dysfunction, strictures, fistulae, and pouchitis.

Advancing Care Through Research and Education

The Global Center works to improve the standard of care nationally and globally through our commitment to high-quality clinical research, global symposia, and the education and training of select fellows. The center’s leadership team has been recognized as top 10 worldwide in terms of impact and influence for the field of colorectal care.

Out-of-State Coordination of Care

For our out-of-state and international patients, the Global Center helps coordinate office appointments, testing, surgery, postoperative care, and follow-up to make travel and care easy for patients coming from far away. Information on accommodation in the NY/NJ area that allows easy access to the Global Center for consultations, procedures, and surgery is readily available.

Our Team

The team members of the Continent Ileostomy Program have vast expertise in the creation, salvage, troubleshooting, and care coordination of the continent ileostomies.

Colorectal Surgeons

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Pokala Ravi Kiran, MD

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James M. Church, MD

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Marco Bertucci Zoccali, MD

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Usama Ahmed Ali, MD, PHD
 

Wound Ostomy Continence Nurse

Erin Testerman, RN, BSN

Vanessa Marra, RN, BSN

Colorectal NPs

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Anna Varghese, NP

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Louella Escoto-Ortaliz, NP

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Venessa Smith, NP

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Razia Khan, RN
 

Global Center Gastroenterologists

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Bo Shen, MD

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Le-Chu Su, MD, PhD, AGAF
 

Gastroenterology & Pelvic Floor NPs & RNs

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Princy Daniel, FNP-BC

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Gerthy Michel, MSN, APRN, FNP-BC

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Abigail Oberc, RN
 

Physician Assistants (Colorectal/Gastroenterology)

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Christian Munoz Pineda, PA Inpatient Colorectal Surgery/Gastroenterology

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Danny Shlomo, PA Inpatient Colorectal Surgery/Gastroenterology

Nutrition

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Sabrina Oliver, MS, RD | (347) 712-0894

Our Locations

Washington Heights

NYP/Columbia University Irving Medical Center (Main Campus)
Herbert Irving Pavilion
161 Fort Washington Avenue, 8th Floor
New York, NY 10032-3784
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Midtown West

51 West 51st Street, Suite #380
New York, NY 10019
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Upper East Side

12 East 86th Street, Suite #1
New York, NY 10028
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New Jersey

330 Grand St
Hoboken, NJ 07030
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Global Center Research & Advances

Landmark research

1. Jarrar A. Church J. Advancement flap repair: a good option for complex anorectal fistulas. Dis Colon & Rectum. 2011; 54:1537-41.
2. Burke J, Church J. Rectal Advancement Flap for the treatment of fistula in ano. Colorectal Disease 2015; video
3. El-Gazzaz G, Hull T, Church JM. Biological immunomodulators improve the healing rate in surgically treated perianal Crohn's fistulas. Colorectal Dis. 2012; 14: 1217-23.

Recent advances within the Columbia Global Center

Role of microbiome

On the basis of an innovative study on microbiome, our providers were the first to propose the idea that there may exist certain enteric bacteria associated with a higher recurrence rate following anal fistula repair. While this research is still ongoing, its findings could invoke a biologic basis for surgical failure following surgery for fistula and inform a personalized medicine approach to antibiotic decontamination of the fistula site prior to surgery.

Endoscopic management of anorectal, rectovaginal and enteroenteric and enterocutaneous fistula

Our team’s expertise in interventional endoscopic techniques for inflammatory bowel disease, structural problems related to the colon and rectum, and correction of surgical complications lends itself to extending these techniques for the management of simple and complex fistulas related to the gastrointestinal tract. This includes anorectal, rectovaginal, pouch related,  enteroenteric and enterocutaneous fistula.

Make an Appointment

To make an appointment with the Complex Anal Fistula Program Program at the Global Center for Integrated Colorectal Surgery & IBD Interventional Endoscopy, please call us at (212) 342-1155.

We accept a number of insurance plans, and our team can help confirm your coverage. 

Resources & More

Stories & Perspectives

• State of the Union Conversation: Members of Columbia’s Global Center discuss colorectal surgery and care, improving surgical training, and how they approach treating conditions.
• Read more colorectal news and stories here