Maarten van Egmond

54 Chapter 3 DISCUSSION This is the first prospective study that systematically described the course of functional status of patients undergoing esophagectomy from 3 months before until 3 months after surgery. This study showed that functional status of patients with esophageal cancer treated with esophagectomy was on average higher compared to normative values at 3 months and at 1 day before surgery and returned to baseline levels 3 months postoperatively with an expected decline directly after surgery. Although patients had significantly less HGS at T4 than at baseline and experienced more fatigue, the differences could be clinically interpreted as minimal. The same pattern was observed in patients who suffered from postoperative complications. Furthermore, this study showed that the course of functional status between patients with and without postoperative complications was not different. The length of hospital stay was clearly longer for patients suffering from postoperative complications, but 3 months after surgery, there was no difference in functional status between patients with and without postoperative complications. These results are surprising because patients with esophageal cancer are considered high-risk for developing postoperative complications with a delayed postoperative recovery. 2,4,7 The incidence of postoperative complications in our study cohort was 53.5%, but despite this, all patients recovered to their baseline functional status 3months after surgery. This seems contradictory to the results of several studies that described the positive effects of improved preoperative functional status on postoperative outcomes in comparable surgical populations. 1,3,4,30 In a recent study by Minnella et al. 31 , the effects of a prehabilitation intervention on functional capacity were investigated in patients with esophageal cancer undergoing surgery. A significant improvement in functional capacity was found in patients who received a prehabilitation intervention, although no differences were found with respect to the incidence of postoperative complications, length of hospital stay and readmission rates. 31 Hulzebos et al. 30 demonstrated that preoperative inspiratory muscle training decreased the incidence of postoperative pulmonary complications and length of hospital stay compared to usual care in patients undergoing coronary artery bypass graft (CABG). However, preoperative pulmonary function in their study cohort was on average 20% lower than predicted, while it was up to 15% higher than predicted in our study cohort. 30,32 Besides, a majority of our study cohort (72.3%) underwent minimally invasive surgery from which is known that it leads to a lower incidence of postoperative pulmonary complications. 33 Moreover, in our study cohort, fewer patients with chronic obstructive pulmonary disease (COPD) and diabetes