Maarten van Egmond

155 General discussion 7 Suggestions for further research Our study population generally contained individuals with few known risk factors for postoperative complications and poor postoperative outcomes. Yet, recent literature has confirmed the association between preoperative risk factors and postoperative outcomes in patient undergoing esophageal cancer surgery, although this association was not found in our population. 21 Therefore, we highly recommend to perform a large observational cohort study consisting of a heterogenous population of patients with esophageal cancer. This would allow for investigating a prediction model of physical functioning and other conventional risk factors to determine whether patients indicated for esophagectomy are at high risk for a delayed postoperative recovery. 38 This model may then be applied for clinical use to differentiate which patients should be referred to a physiotherapist to obtain tailored care to improve pre- and postoperative physical functioning and thereby enhancing postoperative recovery. The predictive value of muscle strength and muscle quantity to determine sarcopenia and its functional consequences should be further investigated in a cohort of both sarcopenic and non-sarcopenic patients. Once physiotherapists are able to identify patients who are at risk for sarcopenia, it will allow them to provide these patients with a physiotherapeutic intervention to increase muscle mass and muscle strength, which might subsequently improve postoperative recovery and functional outcome. 9,24 Finally, the applicability of a postoperative eHealth intervention involves more than feasibility and positive satisfaction. Although we found equal physical functioning outcomes between the intervention and historical control group three months after surgery, we suggest performing a randomized controlled trial for only these patients at high risk for poor postoperative functional recovery, to draw firm conclusions on its effectiveness. General conclusion This thesis was aimed at investigating the pre- and postoperative course of physical functioning in patients with esophageal cancer undergoing elective surgery and to identify factors associated with poor postoperative physical recovery. Contrary to the course of physical functioning of many comparable high-risk surgical populations, our studies illustrated that preoperative physical functioning was higher than predicted, returned to baseline values three months postoperatively and that the course of physical functioning did not systematically differ between patients with and without postoperative complications.