Cervical Anastomotic Leakage After Minimally Invasive McKeown Esophagectomy in the SAFER Surgical System: Clinical Course and Predictors of Delayed Healing

Cervical anastomotic leakage (AL) remains a major complication after esophagectomy. We investigated the clinical course of cervical AL after minimally invasive McKeown esophagectomy within the SAFER surgical system and identified predictors of delayed healing.

This retrospective study included 517 consecutive patients who underwent minimally invasive McKeown esophagectomy with retrosternal reconstruction under SAFER between January 2023 and December 2025. Among them, 50 developed cervical AL. A posterior mediastinal comparator cohort of 37 patients with cervical AL was included for comparison of leak severity and healing outcomes. AL severity was assessed using ECCG and Clavien-Dindo classifications. Cox regression was used to identify predictors of time to closure.

In SAFER group, cervical AL occurred in 50 of 517 patients (9.7%). Compared with the historical same-surgeon PM leakage cohort, SAFER related leaks showed a lower severity profile, with fewer advanced ECCG events and a less severe Clavien-Dindo distribution. All SAFER group patients with cervical AL achieved eventual healing, and the median time to closure was shorter in the SAFER group. Low postoperative day 1 serum albumin (< 35 g/L) independently predicted delayed healing. Patients with low albumin had longer healing time and longer postoperative hospitalization.

Within the SAFER surgical system, cervical AL after minimally invasive McKeown esophagectomy was predominantly low grade, manageable, and ultimately healed in all affected patients. Postoperative day 1 serum albumin may help identify patients at risk of prolonged recovery.