Impact of Ivor Lewis oesophageal surgery on breathing movements: A secondary analysis of a randomised controlled study

Impact of Ivor Lewis oesophageal surgery on breathing movements: A secondary analysis of a randomised controlled study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Ivor Lewis oesophageal surgery on breathing movements: A secondary analysis of a randomised controlled study Monika Fagevik-Olsén, Niklas Sinderhom Sposato, Elsa Svanhall, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8389330/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background: Limitations in chest-wall function and chronic respiratory impairment are well-known side effects after especially open oesophageal resection. There are no trials evaluating breathing movements after oesophageal resection and whether there is any impact on pre- and postoperative training interventions. The aim was to describe and analyse breathing movements before and after thoracoabdominal oesophageal resection and also to evaluate the impact of a rehabilitation intervention. Method: A subset of patients involved in a randomised, controlled trial assessing the effects of a pre- and postoperative training interventions underwent evaluation of breathing movements using a Respiratory Movement Measuring Instrument, both prior to and three months postoperatively. We included in total 38 patients, of which 20 underwent pre- and postoperative interventions comprising physical and respiratory training, and 18 served as controls. The training included respiratory muscle training, four strength training exercises, and enhanced general physical activity. Results: Postoperative breathing movement decreased in the control group (-2.0 mm on the surgical right side and -1.5 mm on the left side), while the intervention group showed a smaller reduction and even a median increase (+2.7mm on the right, and +4.2 mm on the left). Both groups demonstrated a wide range of interindividual variation. Conclusion: An open access (thoracotomy) Ivor-Lewis oesophageal resection results in decreased breathing movements. A specific pre- and postoperative training intervention resulted in less deterioration. Trial registration: ClinicalTrials.gov (NCT03452319), registered 23 February 2023; FoU i VGR: 238651. Trial title: Effects of Increased Physical Activity Before Thoracoabdominal Esophageal Surgery. Ivor Lewis oesophageal surgery Breathing movements Rehabilitation Thoracic mobility Figures Figure 1 Background Each year, more than 500,000 people worldwide are affected by oesophageal cancer, making it one of the most common malignancies ( 1 ). The standard treatment often involves a combination of chemotherapy and surgery, where the Ivor Lewis procedure is the most frequently performed esophagectomy in Sweden due to more cases of adenocarcinoma than squamocellular carcinoma. This approach includes both an abdominal and a thoracic procedure, and if a thoracotomy is performed the chest wall is opened between the fifth and sixth ribs. While this surgery is lifesaving, it has significant consequences for respiratory function and musculoskeletal mobility ( 2 , 3 ). For this reason, the access to the thoracic cavity has become more minimal invasive. Nowadays more procedures are performed via video assisted thoracoscopy (VATS). Even so, in the early postoperative period, there is an increased risk of pulmonary complications, partly due to diaphragmatic dysfunction, which is known to occur following upper abdominal surgery ( 4 ). After open thoracotomy studies have reported a decrease in lung volumes of 40 to 60% during the first postoperative week, further exacerbating respiratory challenges ( 5 , 6 ). This article focuses on open access thoracotomy, even though this approach is less used nowadays. However, this extremely invasive approach is still used, and many patients live with the aftermath of it. In addition, the results may constitute a point of comparison with the less invasive techniques more commonly performed today. Pain in the chest wall is common due to the thoracotomy ( 7 ), which postoperatively may lead to avoidance of deep breaths, subsequently increasing the risk of pulmonary complications such as hypoxia and pneumonia ( 8 ). These effects can extend beyond the immediate recovery period, affecting thoracic mobility and respiratory efficiency in the long term ( 2 ). To counteract these consequences, pre-and postoperative physiotherapy interventions, including respiratory muscle training, thoracic mobility exercises, and general physical activity, are used. However, there is limited knowledge on how these interventions impact thoracic breathing movement patterns postoperatively and whether structured prehabilitation and rehabilitation strategies can mitigate deterioration in breathing function. Given these challenges, the objective of this secondary analysis was to initiate a deeper exploration on thoracic breathing movements following Ivor Lewis oesophagectomy and correlation between the movements and spirometry, respiratory muscle strength, and thoracic expansion. In addition, this report seeks to provide a perspective on rehabilitation strategies that may mitigate postoperative deterioration and support recovery. Methods and Materials This article is based on a group of patients who participated in a randomised, controlled multi-centre trial evaluating the effect of a physical intervention before and after oesophageal resection. Reporting of this study follows the CONSORT 2025 guidelines for randomised trials, with adaptations appropriate for a secondary analysis. The subset consisted of a consecutive series of patients undergoing Ivor Lewis oesophagus resection at Sahlgrenska University hospital, Gothenburg, Sweden between March 2018 and September 2022. The surgical procedure was primarily performed via thoracotomy. However, five patients (n = 2 control group and n = 3 in the intervention group) underwent thoracoscopic surgery. Exclusion criteria were surgery planned within 2 weeks and injury or disease that restricted thoracic mobility or the possibility to perform the physical exercises included. Eligible patients were contacted directly after the decision of surgery or after adjuvant treatment before surgery. They were given oral and written information and those who accepted gave their written consent. The preoperative visit was scheduled as soon as possible after inclusion. Following baseline testing, patients were randomised to either the intervention group (n = 20) or the control group (n = 18) using a digital randomisation table prepared by a person independent to the study. Allocation was concealed in sealed opaque envelopes prepared by the same person. Demographic data are given in Table 1 . There were no significant differences between the groups at baseline. Standard care All patients received basic preoperative information encouraging physical activity until surgery. Postoperatively, early, and frequent mobilisation was initiated according to clinical routines at the hospital. Positive Expiratory Pressure (PEP) training was conducted every second hour during daytime under healthcare professional staff supervision. Upon discharge, all patients were provided with an exercise programme aimed at improving shoulder and chest mobility. Intervention In addition to standard care, patients in the intervention group received a structured training programme. Preoperatively, they were encouraged to increase daily physical activity by at least 30 minutes at moderate intensity and were given four muscle-strengthening exercises to perform. Inspiratory muscle training (IMT) was carried out according to van Adrichem et al. ( 9 ) but adjusted to be conducted as 3 sets of 10 breaths daily using a resistance equivalent to 60% of the individual’s maximal inspiratory pressure (MIP). Expiratory muscle training (EMT) was performed at 50% of maximal expiratory pressure (MEP). A valve with individually adapted resistance and a manometer was used. Patients performed the training independently and documented each session in a logbook. Postoperatively, patients resumed physical activity as early as possible and were encouraged to continue 30 minutes of activity daily from the second week after discharge. IMT and EMT were continued for three months post-discharge, daily during the first month and three times weekly thereafter. Patients were followed up by telephone two weeks post-discharge. Three months after surgery, a clinical follow-up was conducted by a blinded assessor. Information regarding background characteristics, surgical procedure and complications was retrieved from medical records and the national registry (NREV). Table 1 Demographic data Intervention group (n = 20) Mean (SD) Median (Min-Max) Control group (n = 18) Mean (SD) Median (Min-Max) Sex, female/male 4/16 3/15 Age, years 66.1 (9.9) 67.5 (44–79) 62.8 (6.8) 63 (47–74) Height, cm 170 (0.1) 170 (160–190) 180 (0.1) 180 (170–190) Weight, kg 76.6 (12.4) 78.9 (53–102) 76.8 (10.7) 76 (59–95) Body mass index, kg/m 2 25.3 (4.2) 25.1 (18–34.9) 24 (3.5) 23.8 (19.8–31.9) Breathing movement, which was the focus of interests for this secondary analysis, was measured using the Respiratory Movement Measuring Instrument (RMMI), a validated and highly precise tool for assessing breathing thoraco-abdominal breathing movements ( 10 , 11 ). This instrument contains six lasers mounted on two rods which measure bilateral thoracic breathing movements at the level of the third rib and the xiphoid processus, and abdominal breathing movement, at the level of the umbilicus Measurements were taken preoperatively and three months post-operatively. The registration of breathing movements was performed with the patient in the prone position. Breathing at rest was measured for 30 seconds while the patient was unaware of the test. Breathing movements during maximal deep breathing were recorded over one minute, consisting of four deep breaths where the maximal movements were recorded. Spirometry, (forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), peak expiratory flow (PEF)), was measured with the measuring instrument EasyOne™ (ndd Medical Technologies, US) in a sitting position according to international guidelines ( 12 ). Maximal Inspiratory Pressure (MIP) and Maximal Expiratory Pressure (MEP) was measured in a standardized way while sitting using MicroRPM manometers (Micro Medical/CareFusion, Kent, United Kingdom) ( 13 , 14 ). Thoracic expansion, thoracic circumference at maximal inspiration vs. expiration, was measured at the level of the xiphoid processus with a measuring tape according to instructions by Fagevik Olsén et al ( 15 ). Data analysis and statistics Data is presented as absolute values and percent of predicted values and given in mean (standard deviation or 95% confidence interval) and median (min-max). Changes from pre- to postoperative values were calculated for each group and analysed with Mann Whitney U test between groups and Wilcoxon’s sign text within groups. Results Main results from the secondary analysis of thoracic breathing movement before and after Ivor Lewis oesophagectomy, measured using the Respiratory Movement Measuring Instrument (RMMI) are given in Fig. 1 and Table 2 . There was a decrease in breathing movements in the right and left side of the chest wall at the two measuring points in the group in total, Fig. 1 illustrates the post-operative changes across the measured thoracic regions. Median changes in the intervention group were + 4.6 mm (upper left), + 2.6 mm (upper right), + 2.3 mm (lower left), and + 1.3 mm (lower right). In the control group, corresponding median changes were − 0.6 mm, − 0.3 mm, − 0.3 mm, and − 0.2 mm, respectively. Breathing movements (right side/right and left side) presented as procent predicted at inclusion and three months postoperatively, in the intervention and control group are presented in Table 2 . There was a tendency towards less range of motion in the lower part of thorax in the control group compared to the intervention group but the differences did not reach the level of significance. Table 2 Breathing movements (right side/right and left side) presented as procent predicted at inclusion and three months postoperatively, in the intervention and control group. Mean (standard deviation or 95% Confidence interval), median (min-max) At inclusion Change between inclusion and three months Difference between groups Intervention group (n = 13) Control group (n = 10) p–value Intervention group (n = 13) Control group (n = 10) p–value Mean (95%CI) Effect size Breathing movements, Rest Upper thoracic 55.0 (3.6) 55.3 (48.1–61.2) 52.3 (8.2) 51.8 (32.9–61.0) 0.305 -2.4 (6.1) -3.1 (-12.3-12) 0.1 (6.3) -0.2 (-7.8-9.6) 0.410 -2.6 (-80;2.9) -0.412 Lower thoracic 53.7 (7.1) 56.2 (41.9–63.2) 52.7 (8.9) 53.6 (37.8–64.9) 0.772 -5.2 (6.4) -4.6 (-15.3-7.9) -9.0 (10.5)* -4.7 (-31.0-1.6) 0.879 3.8 (-3.6:11.1) 0.448 Breathing movements, Deep Breaths Upper thoracic 53.9 (4.6) 53.9 (44.4–63.2) 53.0 (6.3) 56.3 (41.6–60.3) 0.698 -1.4 (7.9) -1.8 (-16.3-10) -0.6 (4.2) -1.1 (-6.2-6.7) 0.648 -0.8 (-6.6;5.0) -0.118 Lower thoracic 54.0 (5.6) 54.3 (45.7–63.5) 51.7 (7.8) 51.5 (38.0–69.3) 0.416 -5.5 (5.0)* -5.2 (-13.0-4.1) -8.0 (12.1) -3.7 (-35.4-3.6) 0.784 2.4 (-5.2;10.1) 0.278 * significant difference (p-value < 0.05) compared to preoperative values. Table 3 Thoracic expansion, breathing muscle strength and spirometry at inclusion and three months postoperatively presented as percent of predicted. At inclusion Three months postoperatively Intervention group n = 13 Control group, n = 10 p–value Intervention group n = 13 Control group, n = 10 p–value Thoracic expansion 79 (35) 82 (23–138) 77 (36) 78 (81–149) 0.927 -8.6 (25.2) -13.1 (-45.9-45.9) -19.4 (21.8) -17.2 (-57.6-8.2) 0.140 MIP 104 (34) 95 (69–192) 81 ( 24 ) 82 (31–124) 0.101 6.8 (17.7) 8.6 (-34.2–29.7) 1.6 (19.9) 1.0 (-24.0–40.8) 0.446 MEP 105 ( 24 ) 98 (70–152) 104 (34) 112 (47–171) 0.832 -4.1 (14.3) -7.2 (-18.5-36.9) -16.2 (15.7) -20.0 (39.2–4.3) 0.115 FVC 99 ( 15 ) 102 (73–120) 101 ( 19 ) 96 (81–142) 0.784 -12.1 (9.9) -14.0 (-24.0–8.0) -18.1 (15.4) -19.0 (-40.0–7.0) 0.257 FEV 1 97 ( 14 ) 99 (71–118) 96 ( 12 ) 94 (72–117) 0.784 -11.9 (9.9) -15.0 (-23.0–4.0) -16.1 (10.6) -18.5 (-29.0–4.0) 0.313 PEF 104 ( 15 ) 104 (77–126) 97 ( 15 ) 98 (69–122) 0.186 -5.5 (12.3) -7.0 (-25.0–12.0) -6.5 (16.4) -8.0 (-.29.0–-25.0) 0.784 Thoracic expansion, respiratory muscle strength, and spirometry decreased all postoperatively in both groups except MIP which increased slightly, Table 3 . There were weak correlations (r s 0.05) between difference in breathing movement in total (bilateral at both measuring points) and difference in thoracic expansion, MIP, MEP, FVC, FEV 1 and PEF. Discussion Even though it is well known that thoracotomy leads to permanent chest wall restrictions, no previous studies have explored its impact on breathing movement. On a group level, the results from the study at hand indicate a chronic impairment. However, patients who participated in structured prehabilitation and postoperative training in this study tended to demonstrate better preservation of thoracic movement compared to controls. These findings are consistent with previous research, which suggests that early rehabilitation may help mitigate functional decline in oesophagectomy patients ( 9 , 16 ). This is particularly relevant with regards to shifts in surgical practice, including a move to transition from thoracotomy to thoracoscopic surgery for oesophageal resection. This shift has aimed to reduce surgical trauma and to speed up recovery. However, a recent Swedish study found no significant differences between open and thoracoscopic techniques concerning atelectasis or pleural effusion ( 17 ). These findings suggest that surgical approach alone does not fully explain respiratory compromise and emphasise the importance of physiotherapeutic strategies to optimise recovery regardless of surgical method. As rehabilitation specialists and clinicians refine post-operative care, there is an opportunity to explore how best to integrate musculoskeletal support into standard protocols. While respiratory training remains a cornerstone of rehabilitation, additional and refined interventions could enhance patient recovery, including but not limited to: a) Pre-operative inspiratory and expiratory muscle training to optimise respiratory effort and support thoracic mobility ( 18 , 19 ), b) Post-operative thoracic mobility-focused exercises to encourage movement patterns and maintain functional range of motion ( 20 , 21 ), and c) Pain management strategies to facilitate participation in mobility exercises and overall rehabilitation efforts ( 22 ). Even seemingly minor changes in breathing patterns can significantly affect pulmonary volumes and capacities ( 23 , 24 ). Normal thoracic breathing movements measured with RMMI have been found to average 3.02 mm in the upper and 3.36 mm in the lower thoracic region during tidal breathing, and 18.01 mm and 18.15 mm respectively during deep breathing ( 25 ). These differences are sufficient to maintain proper tidal volumes. Consequently, preserving or restoring as much functional mobility as possible following thoracic surgery is of critical importance. Despite these associations, correlations between breathing movements and other measured respiratory variables were very weak (r s <0.150). All outcome variables are incorporated in respiratory function, but they measure different aspects of breathing. RMMI measure, very specifically, the anterior-posterior changes of the chest wall and abdomen during breathing. The test is performed in supine position. Thoracic expansion measures difference in circumference of the chest wall when standing, MIP and MEP breathing muscle strength and spirometry measures lung volumes and flows, are performed in the sitting position. The diversity of outcomes but also the difference in posture may have had impact on the results. However, based on current knowledge none of the other outcomes can replace measurements of the breathing movements. Although these findings suggest a potential benefit, the sample size is small, and further research is necessary to validate these observations. Given the small sample size and the wide interindividual variation, the median increase in breathing movement seen in the intervention group must be interpreted with caution. Individual response to intervention but also to normal variations in recovery trajectory may have affected the positive results indicated by this study. Furthermore, a minority (n = 5) participants underwent thoracoscopic surgery, which may have introduced some variation in terms of impact- and recovery from the procedure compared to those who underwent thoracotomy. Larger trials are therefore warranted to secure both statistical significance and clinical relevance of these added interventions. Additionally, investigating individual differences in response to rehabilitation strategies may help tailor interventions to maximise benefits for different patient populations. Conclusion This explorative study indicates a functional decline on a group level, but also that structured rehabilitation efforts pre- and post-surgery may mitigate negative effects on thoracic mobility and breathing patterns following Ivor Lewis oesophagectomy. However, given the limited number of participants, the results should primarily be regarded as indicative, guiding the direction for future full scaled investigations. Particular attention should be given to how physiotherapy and other musculoskeletal expertise can be more effectively integrated in multidisciplinary care to support recovery in this patient group. Declarations Ethics approval and consent to participate The ethical premise for this study was based on the Declaration of Helsinki for human research. Swedish Ethical Review Authority (Registration number: 542–17). The patients gave their written consent to participate after verbal and written information. Consent for publication All authors have given their consent for publication. Competing interests The authors declare no competing interests. Funding No external funding was received. Author Contribution MFO had full access to all the data in the study and was responsible for the integrity of the data and the accuracy of the data analysis. Concept and design: MFO. Acquisition MFO Statistical analysis: MFO and statistical consultants . Interpretation of results: MFO, NSS, ES, LO CEM Critical revision of the manuscript: MFO, NSS, ES, LO CEM All authors read and approved the final manuscript and accepted responsibility for all aspects of the work. Acknowledgements We thank the clinical teams and patients who contributed to the study. Data Availability Data are available from the corresponding author upon reasonable request. References Uhlenhopp DJ, Then EO, Sunkara T, Gaduputi V. Epidemiology of esophageal cancer: update in global trends, etiology and risk factors. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8389330","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":580176066,"identity":"a1edd02f-bdbe-46bd-9bff-0e4e61dbe311","order_by":0,"name":"Monika Fagevik-Olsén","email":"data:image/png;base64,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","orcid":"","institution":"Gothenburg University","correspondingAuthor":true,"prefix":"","firstName":"Monika","middleName":"","lastName":"Fagevik-Olsén","suffix":""},{"id":580176067,"identity":"45dce137-0c4a-4dfc-94e1-a5b850cab6b6","order_by":1,"name":"Niklas Sinderhom Sposato","email":"","orcid":"","institution":"Gothenburg University","correspondingAuthor":false,"prefix":"","firstName":"Niklas","middleName":"Sinderhom","lastName":"Sposato","suffix":""},{"id":580176068,"identity":"5c8d3028-b372-43a8-8809-f51d74d8ed1d","order_by":2,"name":"Elsa Svanhall","email":"","orcid":"","institution":"Gothenburg University","correspondingAuthor":false,"prefix":"","firstName":"Elsa","middleName":"","lastName":"Svanhall","suffix":""},{"id":580176069,"identity":"2f09a900-7105-4b60-857b-3fe21d6ed31e","order_by":3,"name":"Louise Persson","email":"","orcid":"","institution":"Gothenburg University","correspondingAuthor":false,"prefix":"","firstName":"Louise","middleName":"","lastName":"Persson","suffix":""},{"id":580176070,"identity":"04b2f27d-c987-4885-95c0-b86c3c953cb9","order_by":4,"name":"Cecilia Engström Mattisson","email":"","orcid":"","institution":"Gothenburg University","correspondingAuthor":false,"prefix":"","firstName":"Cecilia","middleName":"Engström","lastName":"Mattisson","suffix":""}],"badges":[],"createdAt":"2025-12-17 21:53:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8389330/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8389330/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101363760,"identity":"4c1467ee-1306-480b-a19f-ae59633b7cc2","added_by":"auto","created_at":"2026-01-29 00:39:01","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":135907,"visible":true,"origin":"","legend":"\u003cp\u003ePost-operative change in thoracic breathing movement (mm) in patients undergoing Ivor-Lewis oesophagectomy, presented by region (upper and lower thorax, left and right side) and group.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8389330/v1/819f36ea2dd26c2d88fc73e0.jpeg"},{"id":101363780,"identity":"4b6b51ff-3e3f-4cd1-843f-48fb70280c2a","added_by":"auto","created_at":"2026-01-29 00:39:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":764431,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8389330/v1/bd146232-6a6f-49f1-9e66-c6976ee2534d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Ivor Lewis oesophageal surgery on breathing movements: A secondary analysis of a randomised controlled study","fulltext":[{"header":"Background","content":"\u003cp\u003eEach year, more than 500,000 people worldwide are affected by oesophageal cancer, making it one of the most common malignancies (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The standard treatment often involves a combination of chemotherapy and surgery, where the Ivor Lewis procedure is the most frequently performed esophagectomy in Sweden due to more cases of adenocarcinoma than squamocellular carcinoma. This approach includes both an abdominal and a thoracic procedure, and if a thoracotomy is performed the chest wall is opened between the fifth and sixth ribs. While this surgery is lifesaving, it has significant consequences for respiratory function and musculoskeletal mobility (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). For this reason, the access to the thoracic cavity has become more minimal invasive. Nowadays more procedures are performed via video assisted thoracoscopy (VATS). Even so, in the early postoperative period, there is an increased risk of pulmonary complications, partly due to diaphragmatic dysfunction, which is known to occur following upper abdominal surgery (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). After open thoracotomy studies have reported a decrease in lung volumes of 40 to 60% during the first postoperative week, further exacerbating respiratory challenges (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This article focuses on open access thoracotomy, even though this approach is less used nowadays. However, this extremely invasive approach is still used, and many patients live with the aftermath of it. In addition, the results may constitute a point of comparison with the less invasive techniques more commonly performed today.\u003c/p\u003e \u003cp\u003ePain in the chest wall is common due to the thoracotomy (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), which postoperatively may lead to avoidance of deep breaths, subsequently increasing the risk of pulmonary complications such as hypoxia and pneumonia (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). These effects can extend beyond the immediate recovery period, affecting thoracic mobility and respiratory efficiency in the long term (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). To counteract these consequences, pre-and postoperative physiotherapy interventions, including respiratory muscle training, thoracic mobility exercises, and general physical activity, are used. However, there is limited knowledge on how these interventions impact thoracic breathing movement patterns postoperatively and whether structured prehabilitation and rehabilitation strategies can mitigate deterioration in breathing function. Given these challenges, the objective of this secondary analysis was to initiate a deeper exploration on thoracic breathing movements following Ivor Lewis oesophagectomy and correlation between the movements and spirometry, respiratory muscle strength, and thoracic expansion. In addition, this report seeks to provide a perspective on rehabilitation strategies that may mitigate postoperative deterioration and support recovery.\u003c/p\u003e"},{"header":"Methods and Materials","content":"\u003cp\u003eThis article is based on a group of patients who participated in a randomised, controlled multi-centre trial evaluating the effect of a physical intervention before and after oesophageal resection. Reporting of this study follows the CONSORT 2025 guidelines for randomised trials, with adaptations appropriate for a secondary analysis. The subset consisted of a consecutive series of patients undergoing Ivor Lewis oesophagus resection at Sahlgrenska University hospital, Gothenburg, Sweden between March 2018 and September 2022. The surgical procedure was primarily performed via thoracotomy. However, five patients (n\u0026thinsp;=\u0026thinsp;2 control group and n\u0026thinsp;=\u0026thinsp;3 in the intervention group) underwent thoracoscopic surgery. Exclusion criteria were surgery planned within 2 weeks and injury or disease that restricted thoracic mobility or the possibility to perform the physical exercises included.\u003c/p\u003e \u003cp\u003eEligible patients were contacted directly after the decision of surgery or after adjuvant treatment before surgery. They were given oral and written information and those who accepted gave their written consent. The preoperative visit was scheduled as soon as possible after inclusion. Following baseline testing, patients were randomised to either the intervention group (n\u0026thinsp;=\u0026thinsp;20) or the control group (n\u0026thinsp;=\u0026thinsp;18) using a digital randomisation table prepared by a person independent to the study. Allocation was concealed in sealed opaque envelopes prepared by the same person.\u003c/p\u003e \u003cp\u003eDemographic data are given in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. There were no significant differences between the groups at baseline.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStandard care\u003c/h2\u003e \u003cp\u003eAll patients received basic preoperative information encouraging physical activity until surgery. Postoperatively, early, and frequent mobilisation was initiated according to clinical routines at the hospital. Positive Expiratory Pressure (PEP) training was conducted every second hour during daytime under healthcare professional staff supervision. Upon discharge, all patients were provided with an exercise programme aimed at improving shoulder and chest mobility.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eIn addition to standard care, patients in the intervention group received a structured training programme. Preoperatively, they were encouraged to increase daily physical activity by at least 30 minutes at moderate intensity and were given four muscle-strengthening exercises to perform. Inspiratory muscle training (IMT) was carried out according to van Adrichem et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) but adjusted to be conducted as 3 sets of 10 breaths daily using a resistance equivalent to 60% of the individual\u0026rsquo;s maximal inspiratory pressure (MIP). Expiratory muscle training (EMT) was performed at 50% of maximal expiratory pressure (MEP). A valve with individually adapted resistance and a manometer was used. Patients performed the training independently and documented each session in a logbook.\u003c/p\u003e \u003cp\u003ePostoperatively, patients resumed physical activity as early as possible and were encouraged to continue 30 minutes of activity daily from the second week after discharge. IMT and EMT were continued for three months post-discharge, daily during the first month and three times weekly thereafter. Patients were followed up by telephone two weeks post-discharge. Three months after surgery, a clinical follow-up was conducted by a blinded assessor. Information regarding background characteristics, surgical procedure and complications was retrieved from medical records and the national registry (NREV).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention group (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003cp\u003e\u003cem\u003eMean (SD)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eMedian (Min-Max)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e \u003cp\u003e\u003cem\u003eMean (SD)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eMedian (Min-Max)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, female/male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4/16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3/15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.1 (9.9)\u003c/p\u003e \u003cp\u003e67.5 (44\u0026ndash;79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.8 (6.8)\u003c/p\u003e \u003cp\u003e63 (47\u0026ndash;74)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight, cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e170 (0.1)\u003c/p\u003e \u003cp\u003e170 (160\u0026ndash;190)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e180 (0.1)\u003c/p\u003e \u003cp\u003e180 (170\u0026ndash;190)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight, kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76.6 (12.4)\u003c/p\u003e \u003cp\u003e78.9 (53\u0026ndash;102)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.8 (10.7)\u003c/p\u003e \u003cp\u003e76 (59\u0026ndash;95)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.3 (4.2)\u003c/p\u003e \u003cp\u003e25.1 (18\u0026ndash;34.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (3.5)\u003c/p\u003e \u003cp\u003e23.8 (19.8\u0026ndash;31.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBreathing movement, which was the focus of interests for this secondary analysis, was measured using the Respiratory Movement Measuring Instrument (RMMI), a validated and highly precise tool for assessing breathing thoraco-abdominal breathing movements (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This instrument contains six lasers mounted on two rods which measure bilateral thoracic breathing movements at the level of the third rib and the xiphoid processus, and abdominal breathing movement, at the level of the umbilicus Measurements were taken preoperatively and three months post-operatively. The registration of breathing movements was performed with the patient in the prone position. Breathing at rest was measured for 30 seconds while the patient was unaware of the test. Breathing movements during maximal deep breathing were recorded over one minute, consisting of four deep breaths where the maximal movements were recorded.\u003c/p\u003e \u003cp\u003eSpirometry, (forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), peak expiratory flow (PEF)), was measured with the measuring instrument EasyOne\u0026trade; (ndd Medical Technologies, US) in a sitting position according to international guidelines (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Maximal Inspiratory Pressure (MIP) and Maximal Expiratory Pressure (MEP) was measured in a standardized way while sitting using MicroRPM manometers (Micro Medical/CareFusion, Kent, United Kingdom) (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Thoracic expansion, thoracic circumference at maximal inspiration vs. expiration, was measured at the level of the xiphoid processus with a measuring tape according to instructions by Fagevik Ols\u0026eacute;n et al (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eData analysis and statistics\u003c/h3\u003e\n\u003cp\u003eData is presented as absolute values and percent of predicted values and given in mean (standard deviation or 95% confidence interval) and median (min-max). Changes from pre- to postoperative values were calculated for each group and analysed with Mann Whitney U test between groups and Wilcoxon\u0026rsquo;s sign text within groups.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eMain results from the secondary analysis of thoracic breathing movement before and after Ivor Lewis oesophagectomy, measured using the Respiratory Movement Measuring Instrument (RMMI) are given in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. There was a decrease in breathing movements in the right and left side of the chest wall at the two measuring points in the group in total, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the post-operative changes across the measured thoracic regions. Median changes in the intervention group were +\u0026thinsp;4.6 mm (upper left), +\u0026thinsp;2.6 mm (upper right), +\u0026thinsp;2.3 mm (lower left), and +\u0026thinsp;1.3 mm (lower right). In the control group, corresponding median changes were \u0026minus;\u0026thinsp;0.6 mm, \u0026minus;\u0026thinsp;0.3 mm, \u0026minus;\u0026thinsp;0.3 mm, and \u0026minus;\u0026thinsp;0.2 mm, respectively.\u003c/p\u003e \u003cp\u003eBreathing movements (right side/right and left side) presented as procent predicted at inclusion and three months postoperatively, in the intervention and control group are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. There was a tendency towards less range of motion in the lower part of thorax in the control group compared to the intervention group but the differences did not reach the level of significance.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBreathing movements (right side/right and left side) presented as procent predicted at inclusion and three months postoperatively, in the intervention and control group. Mean (standard deviation or 95% Confidence interval), median (min-max)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eAt inclusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eChange between inclusion and three months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eDifference between groups\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention group (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl group (n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u0026ndash;value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIntervention group (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eControl group (n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep\u0026ndash;value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMean (95%CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEffect size\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBreathing movements, Rest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUpper thoracic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.0 (3.6)\u003c/p\u003e \u003cp\u003e55.3 (48.1\u0026ndash;61.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.3 (8.2)\u003c/p\u003e \u003cp\u003e51.8 (32.9\u0026ndash;61.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.305\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.4 (6.1)\u003c/p\u003e \u003cp\u003e-3.1 (-12.3-12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.1 (6.3)\u003c/p\u003e \u003cp\u003e-0.2 (-7.8-9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.410\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-2.6 (-80;2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e-0.412\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLower thoracic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.7 (7.1)\u003c/p\u003e \u003cp\u003e56.2 (41.9\u0026ndash;63.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.7 (8.9)\u003c/p\u003e \u003cp\u003e53.6 (37.8\u0026ndash;64.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.772\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-5.2 (6.4)\u003c/p\u003e \u003cp\u003e-4.6 (-15.3-7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-9.0 (10.5)*\u003c/p\u003e \u003cp\u003e-4.7 (-31.0-1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.879\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.8 (-3.6:11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.448\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBreathing movements, Deep Breaths\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUpper thoracic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.9 (4.6)\u003c/p\u003e \u003cp\u003e53.9 (44.4\u0026ndash;63.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.0 (6.3)\u003c/p\u003e \u003cp\u003e56.3 (41.6\u0026ndash;60.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.698\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-1.4 (7.9)\u003c/p\u003e \u003cp\u003e-1.8 (-16.3-10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.6 (4.2)\u003c/p\u003e \u003cp\u003e-1.1 (-6.2-6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.648\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.8 (-6.6;5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e-0.118\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLower thoracic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.0 (5.6)\u003c/p\u003e \u003cp\u003e54.3 (45.7\u0026ndash;63.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.7 (7.8)\u003c/p\u003e \u003cp\u003e51.5 (38.0\u0026ndash;69.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.416\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-5.5 (5.0)*\u003c/p\u003e \u003cp\u003e-5.2 (-13.0-4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-8.0 (12.1)\u003c/p\u003e \u003cp\u003e-3.7 (-35.4-3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.784\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.4 (-5.2;10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.278\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* significant difference (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05) compared to preoperative values.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThoracic expansion, breathing muscle strength and spirometry at inclusion and three months postoperatively presented as percent of predicted.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eAt inclusion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eThree months postoperatively\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention group n\u0026thinsp;=\u0026thinsp;13\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group, n\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u0026ndash;value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIntervention group n\u0026thinsp;=\u0026thinsp;13\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eControl group, n\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep\u0026ndash;value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracic expansion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79 (35)\u003c/p\u003e \u003cp\u003e82 (23\u0026ndash;138)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77 (36)\u003c/p\u003e \u003cp\u003e78 (81\u0026ndash;149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.927\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-8.6 (25.2)\u003c/p\u003e \u003cp\u003e-13.1 (-45.9-45.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-19.4 (21.8)\u003c/p\u003e \u003cp\u003e-17.2 (-57.6-8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.140\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMIP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104 (34)\u003c/p\u003e \u003cp\u003e95 (69\u0026ndash;192)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81\u0026nbsp;(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e82 (31\u0026ndash;124)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.8\u0026nbsp;(17.7)\u003c/p\u003e \u003cp\u003e8.6 (-34.2\u0026ndash;29.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.6 (19.9)\u003c/p\u003e \u003cp\u003e1.0 (-24.0\u0026ndash;40.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.446\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105 (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e98 (70\u0026ndash;152)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e104 (34)\u003c/p\u003e \u003cp\u003e112 (47\u0026ndash;171)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.832\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-4.1 (14.3)\u003c/p\u003e \u003cp\u003e-7.2 (-18.5-36.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-16.2 (15.7)\u003c/p\u003e \u003cp\u003e-20.0 (39.2\u0026ndash;4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.115\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFVC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e102 (73\u0026ndash;120)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e101 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e96 (81\u0026ndash;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.784\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-12.1 (9.9)\u003c/p\u003e \u003cp\u003e-14.0 (-24.0\u0026ndash;8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-18.1 (15.4)\u003c/p\u003e \u003cp\u003e-19.0 (-40.0\u0026ndash;7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.257\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFEV\u003csub\u003e1\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e99 (71\u0026ndash;118)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e94 (72\u0026ndash;117)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.784\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-11.9 (9.9)\u003c/p\u003e \u003cp\u003e-15.0 (-23.0\u0026ndash;4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-16.1 (10.6)\u003c/p\u003e \u003cp\u003e-18.5 (-29.0\u0026ndash;4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.313\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePEF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e104 (77\u0026ndash;126)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e98 (69\u0026ndash;122)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-5.5 (12.3)\u003c/p\u003e \u003cp\u003e-7.0 (-25.0\u0026ndash;12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-6.5 (16.4)\u003c/p\u003e \u003cp\u003e-8.0 (-.29.0\u0026ndash;-25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.784\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThoracic expansion, respiratory muscle strength, and spirometry decreased all postoperatively in both groups except MIP which increased slightly, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. There were weak correlations (r\u003csub\u003es\u003c/sub\u003e\u0026lt;0.150, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) between difference in breathing movement in total (bilateral at both measuring points) and difference in thoracic expansion, MIP, MEP, FVC, FEV\u003csub\u003e1\u003c/sub\u003e and PEF.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eEven though it is well known that thoracotomy leads to permanent chest wall restrictions, no previous studies have explored its impact on breathing movement. On a group level, the results from the study at hand indicate a chronic impairment. However, patients who participated in structured prehabilitation and postoperative training in this study tended to demonstrate better preservation of thoracic movement compared to controls. These findings are consistent with previous research, which suggests that early rehabilitation may help mitigate functional decline in oesophagectomy patients (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This is particularly relevant with regards to shifts in surgical practice, including a move to transition from thoracotomy to thoracoscopic surgery for oesophageal resection. This shift has aimed to reduce surgical trauma and to speed up recovery. However, a recent Swedish study found no significant differences between open and thoracoscopic techniques concerning atelectasis or pleural effusion (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). These findings suggest that surgical approach alone does not fully explain respiratory compromise and emphasise the importance of physiotherapeutic strategies to optimise recovery regardless of surgical method.\u003c/p\u003e \u003cp\u003eAs rehabilitation specialists and clinicians refine post-operative care, there is an opportunity to explore how best to integrate musculoskeletal support into standard protocols. While respiratory training remains a cornerstone of rehabilitation, additional and refined interventions could enhance patient recovery, including but not limited to: a) Pre-operative inspiratory and expiratory muscle training to optimise respiratory effort and support thoracic mobility (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), b) Post-operative thoracic mobility-focused exercises to encourage movement patterns and maintain functional range of motion (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), and c) Pain management strategies to facilitate participation in mobility exercises and overall rehabilitation efforts (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEven seemingly minor changes in breathing patterns can significantly affect pulmonary volumes and capacities (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Normal thoracic breathing movements measured with RMMI have been found to average 3.02 mm in the upper and 3.36 mm in the lower thoracic region during tidal breathing, and 18.01 mm and 18.15 mm respectively during deep breathing (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). These differences are sufficient to maintain proper tidal volumes. Consequently, preserving or restoring as much functional mobility as possible following thoracic surgery is of critical importance. Despite these associations, correlations between breathing movements and other measured respiratory variables were very weak (r\u003csub\u003es\u003c/sub\u003e\u0026lt;0.150). All outcome variables are incorporated in respiratory function, but they measure different aspects of breathing. RMMI measure, very specifically, the anterior-posterior changes of the chest wall and abdomen during breathing. The test is performed in supine position. Thoracic expansion measures difference in circumference of the chest wall when standing, MIP and MEP breathing muscle strength and spirometry measures lung volumes and flows, are performed in the sitting position. The diversity of outcomes but also the difference in posture may have had impact on the results. However, based on current knowledge none of the other outcomes can replace measurements of the breathing movements.\u003c/p\u003e \u003cp\u003eAlthough these findings suggest a potential benefit, the sample size is small, and further research is necessary to validate these observations. Given the small sample size and the wide interindividual variation, the median increase in breathing movement seen in the intervention group must be interpreted with caution. Individual response to intervention but also to normal variations in recovery trajectory may have affected the positive results indicated by this study. Furthermore, a minority (n\u0026thinsp;=\u0026thinsp;5) participants underwent thoracoscopic surgery, which may have introduced some variation in terms of impact- and recovery from the procedure compared to those who underwent thoracotomy. Larger trials are therefore warranted to secure both statistical significance and clinical relevance of these added interventions. Additionally, investigating individual differences in response to rehabilitation strategies may help tailor interventions to maximise benefits for different patient populations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis explorative study indicates a functional decline on a group level, but also that structured rehabilitation efforts pre- and post-surgery may mitigate negative effects on thoracic mobility and breathing patterns following Ivor Lewis oesophagectomy. However, given the limited number of participants, the results should primarily be regarded as indicative, guiding the direction for future full scaled investigations. Particular attention should be given to how physiotherapy and other musculoskeletal expertise can be more effectively integrated in multidisciplinary care to support recovery in this patient group.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ethical premise for this study was based on the Declaration of Helsinki for human research. Swedish Ethical Review Authority (Registration number: 542\u0026ndash;17). The patients gave their written consent to participate after verbal and written information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have given their consent for publication.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eNo external funding was received.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eMFO had full access to all the data in the study and was responsible for the integrity of the data and the accuracy of the data analysis. Concept and design: MFO. Acquisition MFO \u0026nbsp; Statistical analysis: MFO and statistical consultants . Interpretation of results: MFO, NSS, ES, LO CEM Critical revision of the manuscript: MFO, NSS, ES, LO CEM All authors read and approved the final manuscript and accepted responsibility for all aspects of the work.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe thank the clinical teams and patients who contributed to the study.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eData are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUhlenhopp DJ, Then EO, Sunkara T, Gaduputi V. Epidemiology of esophageal cancer: update in global trends, etiology and risk factors. Clin J Gastroenterol. 2020;13(6):1010\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFagevik Ols\u0026eacute;n M, Larsson M, Hammerlid E, Lundell L. Physical function and quality of life after thoracoabdominal oesophageal resection. Dig Surg. 2005;22(1\u0026ndash;2):63\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInoue T, Ito S, Ando M, Nagaya M, Aso H, Mizuno Y et al. Changes in exercise capacity, muscle strength, and health-related quality of life in esophageal cancer patients undergoing esophagectomy. BMC Sports Science, Medicine and Rehabilitation. 2016;8:1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhong J, Zhang S, Li C, Hu Y, Wei W, Liu L, et al. Active cycle of breathing technique may reduce pulmonary complications after esophagectomy: A randomized clinical trial. Thorac cancer. 2022;13(1):76\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBackemar L, Lagergren P, Johar A, Lagergren J. Impact of co-morbidity on mortality after oesophageal cancer surgery. J Br Surg. 2015;102(9):1097\u0026ndash;105.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFagevik Olsen M, Wennberg E, Johnsson E, Josefson K, L\u0026ouml;nroth H, Lundell L. Randomized clinical study of the prevention of pulmonary complications after thoracoabdominal resection by two different breathing techniques. J Br Surg. 2002;89(10):1228\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBayman EO, Parekh KR, Keech J, Selte A, Brennan TJ. A prospective study of chronic pain after thoracic surgery. Anesthesiology. 2017;126(5):938.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMesbah A, Yeung J, Gao F. Pain after thoracotomy. BJA Educ. 2016;16(1):1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Adrichem EJ, Meulenbroek RL, Plukker JT, Groen H, van Weert E. Comparison of two preoperative inspiratory muscle training programs to prevent pulmonary complications in patients undergoing esophagectomy: a randomized controlled pilot study. Ann Surg Oncol. 2014;21:2353\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGunnesson IL, Ols\u0026eacute;n MF. Validity in measuring breathing movements with the Respiratory Movement Measuring Instrument, RMMI. Clin Physiol Funct Imaging. 2011;31(1):1\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOls\u0026eacute;n MF, Romberg K. Reliability of the respiratory movement measuring instrument, RMMI. Clinical physiology and functional imaging. 2010;30(5):349\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuanjer PH, Stanojevic S, Cole TJ, Baur X, Hall GL, Culver BH, et al. Multi-ethnic reference values for spirometry for the 3\u0026ndash;95-yr age range: the global lung function 2012 equations. Eur Respiratory Soc; 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEvans JA, Whitelaw WA. The assessment of maximal respiratory mouth pressures in adults. Respir Care. 2009;54(10):1348\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePessoa I, Sclauser M, Parreira VF, Fregonezi GA, Sheel AW, Chung F, et al. Reference values for maximal inspiratory pressure: a systematic review. Can Respir J. 2014;21(1):43\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOls\u0026eacute;n MF, Lindstrand H, Broberg JL, Westerdahl E. Measuring chest expansion; A study comparing two different instructions. Adv Physiotherapy. 2011;13(3):128\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOverbeek MC, Reijneveld EA, Valkenet K, van Adrichem EJ, Dronkers JJ, Ruurda JP, et al. The association between preoperative inspiratory muscle training variables and postoperative pulmonary complications in subjects with esophageal cancer. Respir Care. 2024;69(3):290\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHannan CJ, Thorisson A, \u0026Ouml;stberg E, Sundbom M, Hedberg J. Radiological comparison of atelectasis formation and pleural effusion after open versus thoracoscopic minimally invasive esophagectomy. Scand J Surg. 2025:14574969251331671.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatsura M, Kuriyama A, Takeshima T, Fukuhara S, Furukawa TA. Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and major abdominal surgery. Cochrane Database Syst Reviews. 2015(10).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMans CM, Reeve JC, Elkins MR. Postoperative outcomes following preoperative inspiratory muscle training in patients undergoing cardiothoracic or upper abdominal surgery: a systematic review and meta analysis. Clin Rehabil. 2015;29(5):426\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFagevik Ols\u0026eacute;n M, Kjellby Wendt G, Hammerlid E, Smedh U. Effects of a training intervention for enhancing recovery after Ivor-Lewis esophagus surgery: a randomized controlled trial. Scand J Surg. 2017;106(2):116\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVolk A, Kennedy-Warbuton R, Twose P. Enhancing early post-operative physiotherapy input to patients undergoing an oesophagectomy: A quality improvement project. 2020 J (52). 2020;52:27\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThompson C, French DG, Costache I. Pain management within an enhanced recovery program after thoracic surgery. J Thorac Disease. 2018;10(Suppl 32):S3773.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKristj\u0026aacute;nsd\u0026oacute;ttir \u0026Aacute;, Ragnarsd\u0026oacute;ttir M, Hannesson P, Beck HJ, Torfason B. Respiratory movements are altered three months and one year following cardiac surgery. Scandinavian Cardiovasc J. 2004;38(2):98\u0026ndash;103.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNozoe M, Mase K, Tsutou A. Regional chest wall volume changes during various breathing maneuvers in normal men. J Japanese Phys Therapy Association. 2011;14(1):12\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRagnarsd\u0026oacute;ttir M, Kristinsd\u0026oacute;ttir EK. Breathing movements and breathing patterns among healthy men and women 20\u0026ndash;69 years of age. Respiration. 2006;73(1):48\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ivor Lewis oesophageal surgery, Breathing movements, Rehabilitation, Thoracic mobility","lastPublishedDoi":"10.21203/rs.3.rs-8389330/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8389330/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Limitations in chest-wall function and chronic respiratory impairment are well-known side effects after especially open oesophageal resection. There are no trials evaluating breathing movements after oesophageal resection and whether there is any impact on pre- and postoperative training interventions.\u003c/p\u003e\n\u003cp\u003eThe aim was to describe and analyse breathing movements before and after thoracoabdominal oesophageal resection and also to evaluate the impact of a rehabilitation intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod: \u003c/strong\u003eA subset of patients involved in a randomised, controlled trial assessing the effects of a pre- and postoperative training interventions underwent evaluation of breathing movements using a Respiratory Movement Measuring Instrument, both prior to and three months postoperatively. We included in total 38 patients, of which 20 underwent pre- and postoperative interventions comprising physical and respiratory training, and 18 served as controls. The training included respiratory muscle training, four strength training exercises, and enhanced general physical activity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003ePostoperative breathing movement decreased in the control group (-2.0 mm on the surgical right side and -1.5 mm on the left side), while the intervention group showed a smaller reduction and even a median increase (+2.7mm on the right, and +4.2 mm on the left). Both groups demonstrated a wide range of interindividual variation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eAn open access (thoracotomy) Ivor-Lewis oesophageal resection results in decreased breathing movements. A specific pre- and postoperative training intervention resulted in less deterioration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e ClinicalTrials.gov (NCT03452319), registered 23 February 2023; FoU i VGR: 238651. Trial title: \u003cem\u003eEffects of Increased Physical Activity Before Thoracoabdominal Esophageal Surgery.\u003c/em\u003e\u003c/p\u003e","manuscriptTitle":"Impact of Ivor Lewis oesophageal surgery on breathing movements: A secondary analysis of a randomised controlled study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-29 00:38:31","doi":"10.21203/rs.3.rs-8389330/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-01-23T09:37:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-22T10:28:12+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-05T10:46:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-02T20:26:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2026-01-02T20:20:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"51de32fa-8942-4b7d-9cc7-c0f0339265d8","owner":[],"postedDate":"January 29th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-29T00:38:31+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-29 00:38:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8389330","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8389330","identity":"rs-8389330","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}