[Establishment of the SAFER low-risk, high-quality surgical system for esophageal cancer: an analysis of 131 cases].

Objective: To address postoperative complications of esophageal cancer, especially anastomotic leakage and the resulting fatal infections, we aimed to establish an optimized surgical system, secure approach for esophagectomy with retrosternal reconstruction (SAFER), centered on the retrosternal reconstruction route, with the goals of reducing surgical risk and enhancing surgical quality. Methods: The SAFER esophagectomy system was developed in collaboration with 9 medical centers in China. We retrospectively analyzed data from 131 consecutive esophageal cancer patients treated at the Cancer Hospital of the Chinese Academy of Medical Sciences and Nanjing Drum Tower Hospital between January and April 2025. All patients underwent thoracoscopic-laparoscopic-assisted three-incision esophagectomy or inflatable mediastinoscopic esophagectomy, with digestive tract reconstruction via the retrosternal route. Key components of the SAFER system included: (1) Standardized total mesoesophageal excision and lymphadenectomy with preservation of the azygos vein arch and right bronchial artery; (2) Gastric mobilization and abdominal lymphadenectomy; (3) Tubular stomach construction and retrosternal tunnel creation; (4) Cervical anastomosis; (5) Enhanced recovery after surgery (ERAS) protocols. Results: There were no perioperative deaths. The anastomotic leakage rate was 5.3% (7/131), significantly lower than the rates reported in most traditional literature (4.2%-22.2%). None of the leakage cases developed systemic infection or organ failure, with an average healing time of 17 days. Other complications included pneumonia (8.4%, 11/131), hoarseness (9.2%, 12/131), and atrial fibrillation (7.6%, 10/131). No chylothorax occurred. Median operative time was 268 minutes, with a median blood loss of 50 ml. The median number of lymph nodes dissected was 36 (19 thoracic + 17 abdominal). Physical status score at 1 week postoperatively was 0-1, and the average hospital stay was 7 days. Conclusions: The SAFER system, utilizing retrosternal reconstruction and other optimized procedures, maximally isolates the tubular stomach and anastomosis from the thoracic cavity, thereby preventing systemic infection caused by anastomotic leakage. Its standardized workflow significantly reduces surgical complexity, ensures oncological resection and standardized lymphadenectomy, and facilitates rapid recovery, providing a safe and high-quality solution for esophageal cancer surgery.