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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.