Prediction of morbidity and mortality after thoracoabdominal esophageal surgery

doi:10.21203/rs.3.rs-3866057/v1

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Prediction of morbidity and mortality after thoracoabdominal esophageal surgery

https://doi.org/10.21203/rs.3.rs-3866057/v1

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Background

Complications after esophagectomy result in higher morbidity and mortality, longer hospital stays and lower quality of life. Unfortunately, we have insufficient knowledge of which patients will tolerate the combination of strenuous oncological therapy and major surgery. This study was designed to evaluate whether additional physical tests, apart from standard preoperative workups, could help identify high-risk patients regarding esophageal cancer surgery.

Methods

A total of 88 patients due to undergo esophagectomy for esophageal cancer were enrolled. In addition to the mandatory physical examinations, seven additional physical therapy tests were carried out within 10 days prior to surgery. CT scans were examined by an experienced radiologist to determine whether patients suffered from sarcopenia. Perioperative data and times of death were gathered from a national register. The primary outcome was the presence of any severe postoperative complication, classified as Clavien-Dindo ≥3, with specific complications as secondary outcomes, and associations between preoperative test performance and complications were examined.

Results

Patients with severe complications had preoperatively performed significantly worse on peak expiratory flow tests (p = 0.013). Patients suffering from anastomotic leakage had shown significantly worse performance on cardiopulmonary exercise testing, whereas the results from shoulder abduction tests were significantly lower in patients who later suffered from pneumonia (p = 0.034 and p = 0.043, respectively).

Conclusion

More extensive preoperative physical examination tests could potentially aid in identifying patients with an increased risk of postoperative complications. Further studies are needed on the subject to corroborate these findings and evaluate their clinical use.

oesophagectomy

complication

peak expiratory flow

shoulder abduction

In Sweden, patients undergoing surgery for esophageal cancer usually receive perioperative chemotherapy or neoadjuvant radiochemotherapy(1). This extensive oncological treatment and major surgery is associated with high morbidity, especially in elderly patients and those with significant comorbidities and poor physical status (2). In addition, dysphagia and cancer cachexia often result in considerable weight loss at the time of diagnosis, adding to the risk of complications (3, 4). Even for patients with resectable tumors, only 34% undergo treatment with curative intent, illustrating the emphasis on patient selection(5). In Sweden, we regularly use spirometry and submaximal exercise testing to complement the clinician’s physical examination.

Several risk factors regarding postoperative complications after esophagectomy have been established, including age, BMI, and chronic obstructive pulmonary disease and sarcopenia, the latter also associated with decreased survival after surgery(6–11). However, improved physical tests could potentially help determine the individual’s overall operability and hence determine treatment recommendations. Several tests have shown the potential to determine the patient’s cardiovascular health, general fitness and pulmonary capabilities(12–14). Studies have also shown promising effects of preoperative prehabilitation(15). Higher preoperative physical activity levels seem to decrease pulmonary complications(16), and prehabilitation, focusing on inspiratory muscle training and exercise, has been shown to reduce postoperative complications and decrease the length of the hospital stay(17).

The aim of this study was to evaluate whether reliable and valid tests of physical strength and stamina could be used as predictors of morbidity and mortality after thoracoabdominal esophageal cancer surgery.

Patients who were due to undergo thoracic abdominal esophagectomy between September 2014 and February 2017 at Sahlgrenska University Hospital, Lund University Hospital or Karolinska University Hospital were asked for their written consent to be enrolled in the study, after receiving appropriate verbal and written information. Inclusion criteria were a planned esophagectomy for cancer and an age of over 18 years. Prior to surgery, the patients met a physiotherapist to perform eight clinically relevant and standardized physical tests, carried out not more than 10 days prior to surgery, with the aim of assessing their cardiopulmonary status and stamina. Patients also completed the mandatory submaximal cardiopulmonary exercise test (CPET)(18) and spirometry, where Peak Expiratory Flow (PEF)(19) and Forced Expiratory Volume (FEV1)(20) was measured.

CT images produced prior to treatment decision were gathered and the total psoas area (TPA)(21) was calculated at level L4 by an experienced radiologist. The TPA was then used to calculate the total psoas index (TPI = TPA/height², cm²/m²), which in turn was compared between groups and, in further analysis, divided into quartiles. Sarcopenia was defined as TPI in the lowest sex-specific quartile(22).

The primary outcome of this study was the presence of any severe complication after surgery, defined as Clavien-Dindo (CD) ≥ 3. The performance in the physical tests, and the presence of sarcopenia, were used as exposure variables, and the associations between the preoperative test results and postoperative complications evaluated. The same analyses were then performed using specific postoperative complications as secondary outcomes: i) anastomotic leakage, ii) bacterial pneumonia, iii) cardiovascular complications, and iv) sepsis.

Physical tests

The following seven physical tests used in the study are methods of examining cardiopulmonary fitness, muscle stamina and general fitness: The six-minute walk distance test (6MWD) measured the total length a patient was able to walk (meters) in six minutes on a 30-meter-long course(13). Maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) were measured with a MicroRPM ™ (Respiratory Pressure Meter: Care Fusion, Sollentuna, Sweden) according to international guidelines. Three attempts were made, and the patient was instructed to exhale and inhale with maximum strength after a maximal inspiration and expiration, respectively (23). Isometric grip strength of the dominant hand was measured using a hand dynamometer (Jamar dynamometer, Patterson Medical ®), while the patient was sitting upright in a chair with his/her arm resting on the armrest(24). We carried out three tests, and the highest value was recorded. The shoulder abduction test was conducted with the patient standing. They were instructed to abduct their shoulders to 90º and hold them as long as possible with weights in his/her hands (2 x 2 kg for women, 2 x 3 kg for men). We allowed a single correction of technique if the arms were seen to be dropping, and the duration of abduction was recorded(25). The timed up and go (TUG) test started with the patient seated in a chair. When the timer started, they were instructed to rise from the chair, walk three meters, turn and then return to the chair and sit down, and the time required for the full motion was recorded(26). A timed-stands test measured the total time it took the patient to stand up and sit down 10 times from a standardized chair with a height of 46 cm, without any support from the arms(27). The heel-raise test measured the amount of time necessary for the patient to perform 10 maximal heel raises as quickly as possible, allowing the arms to be used for support. This test had been modified from the original(28).

In addition, patients filled out the International Physical Activity Questionnaire (IPAQ) short form(29), a questionnaire regarding self-assessed physical activity level. It includes questions about time spent being physically active at vigorous and moderate levels, and time spent walking during the last seven days. It also includes a question concerning time spent sitting during the same period. In the study, a total weekly MET level was calculated, according to guidelines, by multiplying the reported minutes per week in each category by 3.3 for low-intensity activity, 4.0 for moderate-intensity activity, and 8.0 for vigorous-intensity activity(30). The scores from these three categories were consolidated into a total MET-minutes-per-week score, which was categorized into three levels of physical activity, graded ‘low’, ‘moderate’, and ‘high’. Results from the physical tests and the IPAQ results were gathered on site by the responsible physiotherapist.

Epidemiological data

Pre-, peri- and postoperative data were gathered from patient case-records and National Register of Esophagus and Ventricle cancer (NREV), a register with reliable and comparable data(31). The register contributed with the following variables: weight, height, smoking habits, American Society of Anesthesiologists (ASA) score, Zubrod score (WHO score), preoperative chemo- or chemoradiation therapy, perioperative bleeding, length of surgery, localization of the tumor, technique for creating the anastomosis, level of the anastomosis, days in hospital, surgical complications, general complications, Clavien-Dindo classification of the most severe complication, histological type, and tumor-free margins.

Statistical analysis

Continuous variables were first analyzed to determine whether the data was normally distributed. Normally distributed variables were then evaluated using the student’s t-test, and non-normal variables using the Mann-Whitney U test. The chi-squared test or Fisher’s exact test were used for comparing categorical variables. Univariable logistic regression analyses were used to examine the association between exposures and outcomes, and the study was designed to perform a multiple logistic regression using only significant results from the univariable analyses. A two-tailed p-value < 0.05 was considered significant. All statistical analyses were performed using SPSS (IBM SPSS Statistics for Macintosh, Version 25.0).

A total of 114 patients were enrolled in the study. Seven patients were excluded due to metastatic disease, 11 patients due to no esophagectomy being performed, and eight patients for whom no data were found in the register. Altogether, 88 patients were included in the analyses. In this cohort, 24 patients had severe postoperative complications. Thirty–day mortality was zero, but two patients died within 90 postoperative days.

Demographic and complication data are presented in Table 1. The mean age of patients included in the study was 66 years, a majority was male (81%), with a mean body mass index of 26.2 kg/m2, with no significant differences between the two groups. Most patients were diagnosed with adenocarcinoma (80%). Eight patients who were eligible for surgery had an ASA score 3, with the rest either ASA 1 (51%) or ASA 2 (40%). 52% received neoadjuvant radio chemotherapy and 77% perioperative chemotherapy. Patients with severe complications had a longer hospital stay (24 vs 12 days, p-value < 0.005). Overall, the most common complication was anastomotic leakage, followed by bacterial pneumonia, cardiovascular complications, and sepsis.

Table 1

Characteristics of the 88 patients undergoing esophageal surgery
		All (n = 88)	Clavien-Dindo ≥3 (n = 24)	Clavien- Dindo < 3 (n = 64)	P-value
Sex (male)		71 (81)	16 (68)	55 (86)	0.66
Age (y)		66 (60–71)	66 (61–72)	67 (60–71)	0.893
BMI		26.2 (23.8–28.8)	26.5 (24.4–29.4)	25.9 (23.1–28.4)	0.114
Histology	Adenocarcinoma	70 (80)	22 (92)	48 (75)	0.136
	Squamous cell carcinoma	15 (17)	2 (8)	13 (20)	0.222
	Others	3 (3)	0	3 (5)	0.559
ASA	1	44 (51)	15 (65)	29 (45)	0.231
	2	35 (40)	4 (18)	31 (48)	0.007
	3	8 (9)	4 (17)	4 (6)	0.206
Total psoas index (cm²/m²)		8.2 (6.6–9.7)	7.8 (6.3–10.7)	8.4 (6.7–9.6)	0.634
Sarcopenia prior to surgery		20 (22)	5 (21)	15 (23)	0.606
Neoadjuvant chemotherapy		68 (77)	19 (79)	49 (77)	1
Neoadjuvant radiochemotherapy		46 (52)	15 (63)	31 (48)	0.338
Perioperative bleeding (ml)		300 (200–575)	300 (75–600)	300 (200–500)	0.384
Time surgery (min)		469 (405–570)	443 (353–550)	474 (413–570)	0.843
Level of anastomosis	Inferior pulmonary vein	4 (5)	2 (8)	2 (3)	0.571
	Vena azygos	57 (65)	17 (71)	40 (64)	0.617
	Apex of the chest	20 (23)	3 (13)	17 (27)	0.253
	Neck	6 (7)	2 (8)	4 (6)	1
Days in hospital (n)		20 (10–21)	33 (14–45)	15 (9–16)	< 0.005
90-day mortality		2.3%	1 (4)	1 (2)	1
Complications post surgery
General complication		29	12	17	0.075
Surgical complication		23	18	5	< 0.005
Anastomotic leakage		12	11	1	< 0.001
Bacterial pneumonia		9	4	5	0.248
Cardiovascular complications		8	3	5	0.678
Sepsis		7	4	3	0.085
n. recurrens damage		5	2	3	0.611
Pulmonary embolism		2	0	2	0.599
Ductus thoracicus damage		1	1	0	0.273
Other surgical complication¹		4	3	1	0.060
Other general complication²		3	2	1	0.179
1. Ileus, hiatus hernia, lymph leakage and acalculous cholecystitis.
2. Pleural effusion, spleen rupture and pneumothorax.
Continuous variables (25th – 75th percentile), categorical variables (%)

The PEF score was the only significant exposure variable in the analyses of the two Clavien-Dindo groups (p-value 0.013). In the secondary analyses, patients with anastomotic leakage had worse results in the CPET preoperatively (p-value 0.034), whereas performance in the shoulder abduction test was inferior among those who suffered from postoperative pneumonia (p-value 0.043). The results from the main analyses are detailed in Table 2, and from the secondary analyses in Table 3. Results from the main univariable logistic analyses revealed no significant results, as shown in Table 4.

Table 2
	Absolute numbers			Percentage of predicted value (%)
	All (n = 88)	Clavien-Dindo ≥3 (n = 24)	Clavien- Dindo < 3 (n = 64)	All (n = 88)	Clavien-Dindo ≥3 (n = 24)	Clavien-Dindo < 3 (n = 64)	P-value
6MWT (meters)	500 (436–559)¹	510 (450–587)	495 (427–540)	91.9 (79.8-101.8)	90.4 (77.3-101.4)	92.4 (80-102.3)	0.598
MIP (cm H²O)	89 (72–108)	88 (73–107)	89 (72–109)	97.1 (78.9-117.4)	114.8 (82.5-133.2)	96.1 (77.7-113.2)	0.075
MEP (cm H²O)	121 (97–141)	115 (96–133)	123 (97–145)	99 (76–115)	97.5 (85.3-124.5)	99 (75–115)	0.768
Grip strength (kg)	41 (36–48)	39 (32–46)	42 (36–50)	106.5 (93.2-125.4)	121.8 (95-137.6)	101.3 (92.3-122.6)	0.195
Shoulder abduction (sec)	60.8 (40–83)	56.1 (30.9–74)	62.6 (40–83)
TUG (sec)	6.9 (5.4-8)	7 (6.3–7.8)	6.6 (5.3-8)	128.4 (109.4-154.6)	132.3 (117.3-155.5)	124.3 (101.3-155.9)	0.238
Timed-stands (sec)	22.3 (18-27.4)	23.5 (17.4–30.1)	22 (18-26.2)	84.6 (65.3-104.6)	87.5 (69.9-108.3)	82.1 (62.7-101.6)	0.357
FVC (Liters)	3.1 (2.5–3.7)	3 (2.5–3.4)	3.1 (2.5–3.7)	95.5 (87.5–107)	93.5 (81.5–107)	98 (90-107.8)	0.147
FEV1 (Liters)	2.9 (2.5–3.6)	2.9 (2.2–3.6)	2.9 (2.5–3.7)	96 (86-110.5)	95.2 (89–104)	96.4 (84.3-112.3)	0.739
PEF (liters/min)	483.5 (396.8–580)	449.5 (332.5-551.5)	490 (410.5–586)	105 (396.8–580)	99.5 (332.5-551.5)	110.5 (89-119.8)	0.013
CPET (Watt)	151 (111–183)	151 (120–172)	151 (109–185)
Results of the physical examinations
Results of the physical tests performed by the patients undergoing esophageal surgery.
Results in the left columns are absolute numbers of the test results in the two groups (Clavien-Dindo ≥3 and Clavien-Dindo < 3). In the right columns the results are calculated as percentages of the predicted results when using reference values. The percentages are then compared between the two groups.
All variables (25th – 75th percentile), median values used. Reference values, taking sex and age into account, were used in all cases except in CPET and shoulder abduction, which are missing reference values.

Table 3

Results in the physical examinations and the association to specific complications
	Pneumonia			Sepsis			Cardiovascular complications			Anastomotic leakage
	Yes	No	P-value	Yes	No	P-value	Yes	No	P-value	Yes	No	P-value
6MWT (%)	93	91.7	0.831	94.7	91.6	0.632	106.4	90.4	0.007	88.8	92.3	0.477
TIMED-STANDS (%)	76.5	86.3	0.503	85.4	84.5	0.734	82.5	86.3	0.761	104.2	82.7	0.068
TUG (%)	149.9	122.7	0.092	131.4	126.4	0.988	123.2	128.4	0.490	134.6	124.3	0.908
MIP (%)	122	97.1	0.115	116.8	96.6	0.192	114.8	97.1	0.954	112.9	97	0.155
MEP (%)	104.1	122.7	0.103	118.6	120.9	0.859	122	120	0.903	105.8	123.1	0.085
PEF (%)	88.1	103.8	0.105	108	101.6	0.595	96.3	102.7	0.537	101.3	102.2	0.927
FEV1 (%)	85.6	97.4	0.082	100.2	95.8	0.595	98.9	95.9	0.695	94.8	96.3	0.662
Shoulder abduction (sec)	40	63	0.043	62	60	0.892	60	61	0.950	53	62	0.376
Grip strength (%)	123	109	0.148	92.7	112.3	0.075	125.8	109.2	0.111	110.5	110.7	0.976
Heel-rise (sec)	15.2	12.2	0.090	12.8	12.4	0.353	11	12.6	0.982	12.5	12.5	0.754
Exercise test (Watt)	151	151	0.995	136	153	0.357	177	149	0.183	121.9	155.8	0.034
All tests associated with specific complications after surgery using percentage (%) of predicted value. Shoulder abduction, heel-rise and exercise test do not have any sex- and age-specific reference values.

Table 4

Univariate analysis of the results from the physical examinations
		UNIVARIATE ANALYSIS
	No. of patients	Odds Ratio (95% CI)	P-value
MIP	88	1.317 (0.507–3.421)	0.572
MEP	88	1.039 (0.400–2.697)	0.938
6MWT	88	2.400 (0.906–6.357)	0.078
Grip strength	88	0.833 (0.317–2.188)	0.711
TUG	88	1.538 (0.392–6.032)	0.537
Timed-stands	88	1.429 (0.495–4.125 )	0.509
FEV1	88	0.686 (0.255–1.845)	0.455
PEF	88	0.872 (0.334–2.276)	0.779
Sarcopenia	74	1.429 (0.451–4.528)	0.545
Preoperative test results associated with CD≥3 complications. Since no variables were significant in the analysis, a multivariate analysis was not performed.

Neither the level of activity nor of sedentary behavior – according to the IPAQ scores – differed between groups. In the secondary analyses, patients suffering from postoperative pneumonia had a trend toward more sedentary behavior (p-value 0.055). The details of the IPAQ form are depicted in Tables 5 and 6.

Table 5
	ALL (n = 80)	CD≥3	CD < 3	P-VALUE
MET-minutes	5811	4684	6210	0.508
Low physical activity (n)	15	4 (19%)	10 (18%)	1
Moderate physical activity (n)	34	10 (48%)	24 (41%)	0.624
High physical activity (n)	31	7 (33%)	24 (41%)	0.622
Sedentary state (hours)	6.2	6.4	6.2	0.811
The association between physical activity and the severity of post operative complications
IPAQ results gathered prior to surgery compared between the two groups.
The level of activity graded according to IPAQ scoring protocol. IPAQ 4 measures the total time (h) in sedentary state in the last seven days before survey.
A MET-minute is created by multiplying the type of activity (walking, moderate and vigorous) with the total time spent on physical activities during a week. For more information, see IPAQ scoring protocol (30).

Table 6

The association between physical activity and specific post operative complications
	PNEUMONIA			SEPSIS			CARDIOVASCULAR			ANASTOMOTIC LEAKAGE
	Yes	No	P-value	Yes	No	P-value	Yes	No	P-value	Yes	No	P-value
MET- minutes	11470	5166	0.057	6099	5786	0.933	3829	6009	0.536	6150	5757	0.894
Level of activity (n)
Low	2	13	1	3	12	0.93	2	13	0.620	4	11	0.207
Moderate	2	32	0.473	2	32	0.702	3	31	1	3	31	0.356
High	5	26	0.269	31	0	0.091	2	29	0.707	4	27	1
IPAQ 4 (h)	6.46	4.125	0.055	5.383	6.295	0.515	6.714	6.179	0.682	6.367	6.208	0.892
Analysis of results in IPAQ correlation to specific complications.

In this cohort, sarcopenia was defined as TPI < 5.53 cm²/m² for women and < 7.36 cm²/m² for men (22). Sarcopenia was present in 21% and 23% of patients with and without severe complications, respectively (p-value 0.588). The presence of sarcopenia did not result in significantly impaired performance in the tests (see Table 7).

Table 7

The association between results in the physical examination and presence of sarcopenia
	All (n = 74)	Sarcopenia	No sarcopenia	P-value
FVC	99 (90–109)	98 (92–112)	99 (89–109)	0.905
FEV1	95 (25–110)	95 (81–113)	95 (86–109)	0.976
PEF	101 (84–116)	102 (79–112)	100 (84–117)	0.792
MIP	96 (82–120)	105 (96–125)	93 (79–118)	0.202
MEP	99 (85–117)	106 (89–135)	96 (85–113)	0.315
Time-stands	85 (67–104)	91 (70–109)	83 (63–100)	0.225
TUG	134 (114–159)	133 (116–155)	134 (110–160)	0.874
Grip strength	110 (92–126)	122 (105–132)	106 (88–122)	0.025
6MWT	92 (80–102)	94 (82–103)	92 (79–102)	0.648
Comparing percentage of predicted results between patients with sarcopenia prior to surgery (25th – 75th percentile). Only patients with CT scans prior to surgery were included (14 patients missing).

In this multi-center study, we investigated the predictive capabilities of more extensive physical evaluation of the patient regarding the risk of severe complications after esophagectomy for esophageal cancer. Underperformance in spirometry, CPET or shoulder abduction test was associated with a higher incidence of severe postoperative complications.

Complications after esophagectomy range from mild pneumonia to life-threatening anastomotic leakage and sepsis. The ability to correctly select patients with a low risk of debilitating or possibly fatal complications is an important task for any multidisciplinary team meeting, but unfortunately the tools available to do so are not well documented. Consequently, the decision on whether the patient will benefit overall from the intervention often relies mainly on clinical experience.

PEF performance was 90.5% of predicted value in patients who ultimately suffered from severe postoperative complications, compared with 107% of those who did not. This suggests that decreased air flow is a risk factor for developing postoperative complications. Similar findings have been shown in previous studies regarding pulmonary complications after lobectomy(32, 33). PEF may be considered a valuable tool in assessing the patient’s pulmonary status. It is also a cheap and efficient test that could be easily integrated into the preoperative workup of the patient’s physical status.

Similarly, performance on CPET, a test which is often used to estimate operative risk (although the evidence for predicting complications after esophagectomy is sparse), was worse in patients who later suffered from anastomotic leakage (34). Several studies have identified a lower VO₂ max preoperatively to be a predictor of overall postoperative complications(35, 36), while studies specifically examining cardiopulmonary complications have failed to demonstrate any such association(37, 38). Larger patient cohorts seem to be needed to reach a consensus on the ability of the CPET to predict postoperative complications.

In our study, patients with severe complications demonstrated a trend toward a lower level of preoperative physical activity. A small study found a lower level of physical activity to be an independent risk factor for developing postoperative complications after esophagectomy for esophageal cancer(39). The idea that greater physical activity before surgery would lead to fewer postoperative complications seems intuitively reasonable, possibly through a greater reserve capacity. Several studies have shown the potential of prehabilitation in preventing pulmonary complications after surgery(40–42), which has led to larger intervention studies on the subject, such as the PREPARE study(43). Starting rehabilitation with a higher level of overall fitness should likely improve the end results.

We could not show any association between sarcopenia prior to surgery and the incidence of severe complications postoperatively. Similar results have been described in earlier studies(44), but a larger number of studies have shown positive results, linking sarcopenia to morbidity and mortality after major surgery(10, 11, 22). The awareness of sarcopenia and the number of tools to diagnose it have increased in recent years. Grip strength measurements and the TUG test have shown potential in diagnosing sarcopenia and are also recommended in the most recent guidelines(45, 46). In our study, we were also unable to confirm any association between these tests and sarcopenia. However, this study was not designed to establish such an association; the reference values linked to grip strength and TUG listed in the guidelines differ from the test results in this study, which might indicate a difficulty in using the proposed reference values on a group already selected for surgery.

Strengths and limitations

This is a multi-center study with reliable data, either gathered by the authors or obtained from a validated register(47). The included patients constitute a population-based cohort for Sweden’s three largest university hospitals’ catchment areas, corroborated by the fact that demographic data are similar to data reported in NREV(48). All tests included in the analyses are standardized, validated and reliable, making the methods easy to replicate in future studies. Every center assigned the same detailed manual to each test, which makes the results comparable between centers. Furthermore, reference values, adjusted for sex and age, were used for 6MWT, MIP, MEP and grip strength, TUG, timed-stands and FVC, FEV1 and PEF, making comparisons between groups more representable.

All tests used in this study are easy to perform and require almost no extra equipment for the physiotherapist, making them easy to introduce into clinical practice.

Many of the tests were performed not more than 10 days prior to surgery. Except for CPET and spirometry, no additional testing was performed before neoadjuvant oncological therapy. The neoadjuvant therapy often leads to deteriorating physical fitness. If the same tests were performed before the neoadjuvant treatment started, it would be possible to compare the test results and identify the patients with the greatest decline, using patients as their own references, which could be of clinical importance. Similarly, the CT scans used to identify sarcopenia in this study were all performed prior to neoadjuvant therapy. Elliot et al demonstrated a 15% increase in sarcopenia during neoadjuvant oncological therapy, indicating that sarcopenia may be more prevalent among patients undergoing surgery than has been previously understood(49).

Due to the overall lack of earlier studies on the predictive capabilities of phyiscal tests for postoperative complications after esophagectomy, this study was designed as an explorative, hypothesis-generating study. We therefore chose to include several different tests in the study design, in search of results promising enough to motivate further studies on this subject. Esophagectomy is a rather uncommon procedure, yielding small cohorts overall, and even though we have included patients from the three largest catchment areas in Sweden, the study still risks being underpowered overall, and does not allow for adjusting for confounders in multivariable analyses.

This small, explorative, hypothesis-generating study has shown a potential benefit of using some cheap and easily replicable physical tests to determine the overall risk of curative surgery for esophageal cancer. With a greater understanding of the individual patient’s physical preoperative condition, we may be able to identify patients with a higher risk of a complicated course postoperatively, and hopefully better select, inform, and optimize patients before they undergo surgery that, while designed to cure them, might instead harm them.

Ethics approval and consent to participate

Ethical approval for collecting data were acquired from Regionala Etikprövningsnämnden (EPN). Number of approval: 1028-13. All patients in the study did consent to participate in this study and left a written and informed consent.

Consent for publication

Not applicable

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to patient secrecy but are available from the corresponding author on reasonable request.

Funding

Work was supported by grants from the Swedish state under the agreement between the Swedish government and the county councils, the ALF agreement (ALFGBG-718811).

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No competing interests reported.

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Prediction of morbidity and mortality after thoracoabdominal esophageal surgery

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