Predictors of delayed healing after anal fissure surgery: association of Helicobacter pylori infection and intestinal parasitic infestations with healing outcomes—an observational study

Abstract Anal fissure is a common surgical problem. Failure to improve after surgical intervention is mainly due to delayed or incomplete healing. This study aimed to identify factors associated with delayed or no healing after anal fissure surgeries in order to modify potentially preventable risk factors. This is a single-center prospective cohort study that included patients who underwent anal fissure surgery from August 2024 to November 2025. Patients were categorized into two groups based on healing status: normal healing and delayed healing. Data were collected from patients and the follow-up physician, and associations between demographic, clinical, surgical, and infectious factors and healing outcomes were examined using univariable and multivariable analyses. Sensitivity analyses additionally adjusting for diabetes and muscle tone were performed for the infection-related associations. From the analyzed data, the mean age of group I (normal healing) was 40.9 ± 12.4 years and that of group II (delayed healing) was 44.5 ± 12.6 years. Age, BMI (body mass index), number of fissures, type of surgery, energy source, Entamoeba infestation, Helicobacter pylori infection, and Giardia infestation differed significantly between the two groups ( P < 0.05). In unadjusted analyses, V–Y advancement flap, laser fissuroplasty, and lateral internal sphincterotomy were associated with significantly lower rates of delayed healing. After adjustment for age, BMI, and number of fissures, only laser fissuroplasty remained statistically significant. Entamoeba infestation, Helicobacter pylori infection, and Giardia infestation all remained significantly associated with delayed healing after adjustment for age, BMI, and number of fissures, and Entamoeba and H. pylori remained independently associated with delayed healing when included simultaneously in the multivariable model. Sensitivity analyses using Firth’s penalized likelihood logistic regression, and additional models further adjusting for diabetes and muscle tone, yielded consistent findings for all three infections. Delayed healing after anal fissure surgery was associated with older age, female sex, higher BMI, multiple fissures, and positive stool tests for Entamoeba histolytica , Helicobacter pylori, and Giardia, although the association with female sex was of borderline significance. These infection associations remained significant after adjustment for age, BMI, number of fissures, and, in sensitivity analyses, diabetes and muscle tone. V–Y advancement flap, laser fissuroplasty, and lateral internal sphincterotomy were associated with lower rates of delayed healing in unadjusted analyses; however, only laser fissuroplasty maintained statistical significance after multivariable adjustment.