Maarten van Egmond

149 General discussion 7 preoperative physical functioning and postoperative complications (Chapter 2). This is in line with a study of Minnella et al. 12 , who did not find significant differences in the incidence of postoperative complications, length of hospital stays and readmission rates between patients with better preoperative physical functioning than a control group. Muscle strength is highly associated with muscle mass in patients with esophageal cancer Esophageal cancer surgery is associated with significant weight loss due to malnutrition and a loss of muscle mass and muscle strength. 12 This may lead to sarcopenia, a progressive and generalized muscle disorder, that leads to increased morbidity and mortality . 13 Probable sarcopenia is identified by low muscle strength, confirmed by low muscle mass and considered severe in case of low physical performance. 14 Therefore, both muscle strength and muscle mass need to be assessed. 13 However, technologies to measure muscle mass, such as dual x-ray absorptiometry (DXA) and computed tomography (CT) are very expensive or lead to radiation exposure. 14,15 There is a need for clinical methods to easily and rapidly assess muscle mass with minimal patient burden to identify patients with decreased muscle mass. Measurements of muscle mass such as bioelectrical impedance analysis (BIA) and more recently ultrasound assessment are affordable, reliable and valid, but not yet widely available. 16 Therefore, we assessed the association between muscle mass and muscle strength in surgical patients with esophageal cancer prior to CRT. We found an independent association of handgrip strength, respiratory muscle strength and functional lower extremity strength with muscle mass in patients with esophageal cancer awaiting surgery (Chapter 4) .These results could be used to predict muscle mass based on muscle strength in preoperative patients with esophageal cancer. Postoperative physiotherapy at home through eHealth is a feasible alternative to face-to- face care Despite high preoperative physical functioning, the incidence of postoperative complications remained high in patients treated with esophagectomy (Chapter 2) . Patients with postoperative complications after esophagectomy often suffer from fatigue, decreased exercise capacity and disability, which justifies an indication for postoperative physiotherapy. Once discharged from the hospital, patients will face many challenges to manage their own postoperative functional recovery outside of the hospital setting. Although patients are prepared in the hospital for a smooth and seamless transition by providing the appropriate knowledge, education and referral information, the continuation of care in the home situation is not always successful. 15 Especially in vulnerable populations, impediments in social support, challenges with transportation and lack of self-efficacy might prevent them from receiving the appropriate care that contributes to an optimal postoperative functional recovery. 15