Maarten van Egmond

43 The pre- and postoperative course of functional status 3 INTRODUCTION The surgical treatment of esophageal cancer after neoadjuvant chemotherapy consists of curative esophagectomy with gastric tube reconstruction and is associated with a high rate of postoperative complications, up to 60%, and an increased length of hospital stay and poor functional outcome. 1-6 In addition to surgery-related complications, pulmonary and cardiac complications contribute highly to postoperative morbidity. 2,4,7 Impairments in preoperative functional status have been identified as independent risk factors of postoperative complications and delayed postoperative recovery in major abdominal and thoracic surgery. 1,2,5 It is also known that increased preoperative functional status has positive effects on postoperative recovery. 8,9 Physiotherapists play an important role in optimizing functional status both preceding and following esophagectomy. Traditionally, physiotherapy treatment aims at improving postoperative recovery, but gradually, more emphasis has been placed on preoperative physiotherapeutic interventions to improve physical activity (respiratory and cardiovascular capacity and muscle strength), enabling the human body to better withstand external stressors such as surgery. 7,9,10 This is called prehabilitation, and several studies have demonstrated that it leads to a faster postoperative recovery in cardiothoracic surgical populations. 8,9,11,12 Physiotherapeutic prehabilitation has been recommended for the preoperative management of patients with esophageal cancer, but evidence of the effectiveness of specific interventions remains unclear. 10 After surgery, functional status decreases significantly in high-risk surgical populations and tends to recover during the postoperative period with postoperative physiotherapy. 8 However, there is a lack of evidence concerning how functional status develops over time in the pre- and postoperative course of patients with esophageal cancer. Moreover, it is currently unclear how changes in functional status relate to postoperative recovery. It could be hypothesized that patients in poor preoperative condition are not able to adequately respond to the negative effects of surgery, resulting in a delayed postoperative recovery and an increase in morbidity and mortality. In addition, patients suffering from postoperative complications will take longer to recover and regain their functional status, especially if their preoperative functional status is low. Therefore, the main objective of this prospective longitudinal study was to investigate the course of functional status in patients with esophageal cancer before and after esophagectomy. The second objective was to investigate whether the course of functional status was different between patients with and without postoperative complications.