Maarten van Egmond

148 Chapter 7 There may be two reasons for this. First, the incidence of postoperative pulmonary complications was low. This could be explained by the minimally invasive surgical approach being performed in the vast majority of patients. (Chapter 2,3 ). It is known that minimally invasive procedures lead to a lower risk of postoperative pulmonary complications. 7 At the same time, therewas a relatively high incidence of gastrointestinal complications such as esophago-enteric leak fromanastomosis and atrial dysrhythmia, fromwhich it’s arguable that its risk is unrelated to preoperative physical functioning (Chapter 2) . Second, the patients included in our study showed higher pulmonary function and preoperative physical functioning than comparablehigh-risk surgical populations (Chapter 2,3) . Thiswas contrary to a study of Feeney et al. 8 where preoperative pulmonary function and inspiratorymuscle strength in patients with esophageal cancer undergoing surgery, were lower than predicted. In general, the risk of postoperative pulmonary complications is significantly associated with preoperative pulmonary function and inspiratory muscle strength. 8 Therefore, the high preoperative pulmonary function in our study cohort combined with being treated with a minimally invasive surgical approach, may explain the low incidence of postoperative pulmonary complications. 7 Patients with esophageal cancer recover to baseline preoperative physical functioning three months after surgery, irrespective of postoperative complications Until recently, the development of physical functioning over time was not known for patients undergoing esophageal cancer surgery. We found that preoperative physical functioning was higher than predicted based on reference values. Moreover, physical functioning significantly improved in the preoperative phase (3 months until 1 day before surgery) (Chapter 3) . This was despite the neoadjuvant chemoradiation therapy that all patients received, from which it is known that this leads to cardiopulmonary toxicity and decreased aerobic capacity. 3,9 Of note, all aspects of physical functioning returned to baseline levels in our population three months postoperatively, except from fatigue and handgrip strength. This was also confirmed in a study of Lawrence et al. 10 , who found a significant postoperative decline in handgrip strength in older patients undergoing major abdominal surgery, while all other aspects of physical functioning restored to baseline levels. This could be explained by the nutritional impairments patients may suffer from after esophageal cancer surgery, where handgrip strength not only reflects whole body muscle strength, but also nutritional status. 11 Another important finding was that the course of physical functioning over time was not different for patients with and without postoperative complications (Chapter 3). This further contributes to the findings in our previous study, where we did not find an association between