Maarten van Egmond

34 Chapter 2 Second, in previous research the LAPAQ was compared with a diary and pedometer, which were used as validation instruments. Neither the diary nor the pedometer was able to accurately measure PA or validate the findings of the LAPAQ. This problem however, also holds true for other questionnaires. Nevertheless, the LAPAQ appears to be a promising tool for measuring PA in patients with major abdominal surgery. 12 Moreover, Siebeling et al. 30 revealed in their study that LAPAQ underestimates PA. If this finding would be transferred to our population, we could conclude that the reported PA are lower than real, which supports the relatively good functional status of our investigated cohort. From our study, we conclude that despite the high rate of POC, preoperative functional status in our cohort of patients with an esophagectomy probably does not predict POC, irrespective of the surgical procedure. Therefore, preoperative functional status should not always be considered as a risk factor for postoperative complications in high-risk surgical populations per se, but depends on patient- and surgery specific characteristics (i.e. the initial levels of preoperative functional status, the presence of comorbidities, type of surgery and the nature of POC as well). On average, our study cohort scored high on aspects of preoperative functional status, despite the fact that such patients are considered to have a high-risk for developing postoperative complications and a delayed functional recovery. This has also recently been illustrated by a study of Dettling et al. 31 where preoperative training of inspiratory muscles in a comparable esophageal cancer population did not lead to an expected postoperative reduction of POC. The researchers stated that these patients benefited less from inspiratory muscle training than other surgical populations with decreased pulmonary function. Therefore, our study shows that a high incidence of POC is not necessarily related to high levels of preoperative functional status and we question whether increasing preoperative functional status in these relatively fit patients would contribute to a reduced chance of poor postoperative functional recovery. This might be different in other esophago-gastric cancer patients and, therefore, our study emphasizes the need to carefully assess preoperative functional status and relate this to patient- and surgery specific characteristics, before indicating a preoperative training program. We hypothesize that only patients with a low initial preoperative functional status or the presence of comorbidities or other risk factors might benefit from a preoperative training program in order to improve postoperative recovery (Better in- Better out). 32 Additional research to investigate the association in esophagectomy patients with a low preoperative functional status and postoperative pulmonary complications is, therefore, highly recommended.