Maarten van Egmond

153 General discussion 7 Preoperative risk stratification typically allows for determining who may benefit from preoperative improvement of physical functioning. A recent European multicenter cohort study of Klevebro et al. 21 stated that cardiorespiratory comorbidity and impaired pulmonary function are associated with postoperative complications. Therefore, current clinical guidelines even suggest that every high-risk surgical patient should be provided with preoperative physiotherapy to improve physical functioning. 28 This is however debatable, to say the least. There are two different perspectives on the definition of ‘risk’. The first refers to the patient’s individual risk profile of an adverse outcome, such as postoperative pulmonary complications, poor postoperative recovery and mortality, related to the general population. 29 This risk is determined by patient-specific characteristics, such as age, comorbidities and physical functioning before surgical intervention. In that respect, our study population could be considered as ‘lower risk’, since they showed few cardiovascular comorbidities, high pulmonary function and high preoperative physical functioning (Chapter 2) . The second perspective refers to the risks of the specific surgical procedure on adverse outcomes related to all surgical procedures. 29 This second perspective seems to be more applicable to our study population, where more than half of the patients suffered from a postoperative complication despite few cardiovascular comorbidities, high pulmonary function and high preoperative levels of physical functioning. Therefore, knowledge about a patients’ risk not only refers to the individual factors, such as age, comorbidities and physical functioning, but also to factors associated with the type of surgery. 29 Our study clearly showed that the incidence of postoperative complications was high, despite high levels of preoperative physical functioning. Therefore, the question is justified if preoperative improvement of physiological and physical functioning is beneficial for all patients with an indication for esophagectomy. Little improvement in physiological and physical functioning is to be expected if these levels are already high. Moreover, there seemed to be no relationship between preoperative functional status and postoperative complications in our study cohort (Chapter 2) . This illustrates the necessity of a systematic evaluation of both the pre- and postoperative course of physical functioning as well as knowledge about specific patient-, disease- and surgical characteristics, before deciding on whether and when improvement of physical functioning by tailored physiotherapy is indicated, either pre- or postoperatively. This preoperative risk stratification should be performed in every patient with esophageal cancer, based on known individual risk factors and relevant aspects of physical functioning.