Maarten van Egmond

23 Preoperative functional status and postoperative complications 2 INTRODUCTION Esophagectomy, the primary curative treatment for patients with esophageal cancer, is associated with a 60% risk of postoperative complications (POC). 1-3 POC contribute highly to postoperative morbidity and may lead to an increased length of hospital stay, delayed postoperative functional recovery, a reduced quality of life and cost ineffectiveness. 2,4,5 In major thoracic and abdominal surgery, preoperative functional status has been shown to be a risk factor for POC and subsequently a delayed postoperative functional recovery. 6 Functional status is a multi-dimensional concept defined as ‘a patient-oriented health outcome that contains aspects of individual daily functioning including physical, psychological and social factors’ . 7,8 It is essential in achieving and maintaining functional independence, a common prerequisite for hospital discharge and independent functioning and autonomy of an individual in society. 9 Physiotherapeutic treatment, aimed at improvement of preoperative functional status, enables the human body to better withstand external stressors like surgery. 4,9 Several studies reported that an increase of inspiratory muscle strength (IMS) and handgrip strength (HGS), as physical indicators of functional status, reduce POC in major thoracic and abdominal surgery. 10,11 Other indicators of functional status, physical activities (PA) and health- related quality of life (HRQL), are both firm predictors of postoperative outcome and seem to be associated with postoperative morbidity, mortality and length of hospital stay. 12-14 It is generally known that preoperative improvement of functional status enables the human body to better withstand external stressors like surgery. 4,9 This is called prehabilitation and may lead to a faster postoperative recovery. 9 Although preoperative functional status is associated with a reduction of POC after major abdominal and thoracic surgery, this has hardly been evaluated in patients with esophageal cancer awaiting esophagectomy. 1,5,10,15 To determine whether these patients are at risk for developing POC and poor postoperative functional outcome, preoperative levels of functional status should be carefully evaluated. 6 If preoperative functional status of patients with esophageal cancer could predict POC, it would enable physiotherapists to identify patients that could benefit from tailored physiotherapeutic treatment to improve preoperative functional status and consequently decrease the risk of POC. Therefore, a valid prediction model is needed. In this prospective cohort study, we determined associations between IMS, HGS, PA and HRQL as indicators of functional status with POC in patients with esophageal cancer undergoing esophagectomy.