Maarten van Egmond

154 Chapter 7 Physical exercise and nutrition The individual risk for poor postoperative outcome in patients diagnosed with esophageal cancer is further determined by a patient’s nutritional status. 1,30 Malnutrition is a combination of inadequate intake and increased protein requirements, hypermetabolism and hypercatabolism that alter nutrient utilization with as a consequence cachexia, manifested in a poor physical functioning and lowmetabolic reserve. 24,31 This may ultimately result in sarcopenia, a phenotypic feature of cachexia, leading to a reduced overall survival compared to non-sarcopenic patients. 24 Therefore, the risk of sarcopenia should be identified as early as possible after being diagnosed with esophageal cancer. 24 Patients with a high risk of malnutrition are highly recommended to follow a multimodal treatment containing exercise resistance training with nutritional therapy to avoid sarcopenia. 12,31 Although our study population hardly contained sarcopenic cases, it still remains important to identify individuals at risk before surgery from a preventative perspective, taking in to consideration the prevalence of sarcopenia up to 35% one year post-esophagectomy. 11 Our study showed an association between muscle strength and muscle mass, which facilitates the early identification of individuals with probable sarcopenia and the functional consequences in patients with esophageal cancer, as suggested by the European Working Group on Sarcopenia in Older People (EWGSOP). 14,32,33 Bridging the gap between hospital and primary care In Chapter 6 we showed that postoperative recovery of patients with esophageal cancer suffering from postoperative complications after hospital discharge could be managed with physiotherapy through eHealth in a patient’s home situation. 34 Physiotherapy with eHealth allows patients to perform their exercises at home flexibly and more frequently with reduced traveling time and costs and without extra face-to-face visits. 34-36 Moreover, physiotherapy through eHealth could be a valuable tool to overcome discontinuities that may arise in communication between hospital and primary care physiotherapy just after hospital discharge. 20 It allows for a smooth transition of knowledge about disease specific issues as well as expertise required to provide physiotherapy at home. 15 In addition, eHealth applications allow for improving interdisciplinary coordination and integration of care in complex patients. 37 Therefore, as restrictions in physical functioning may be profound in patients with postoperative complications after complex surgery, physiotherapeutic interventions through eHealth should be strongly considered to improve physical functioning in a patient’s home situation, especially in the first period after discharge.