The original description of the lower extremity bypass (LEB) provided surgeons with a reliable method of limb revascularization. The tenets of the operation have formed the foundation for the advances of surgical care. A careful evaluation of the chronic limb-threatening ischemia patient due to the numerous comorbid conditions is paramount to obtain the best possible outcomes. Use of all adjuncts including judicious target vessels control, completion imaging, and vein harvesting techniques to ensure optimal outcomes because a functioning LEB remains a key to successful limb salvage.

Introduction: The purpose of this study was to create a system to assess surgical complexity by developing an objective composite risk score (CRS) using postoperative adverse outcomes from high-quality ACS NSQIP clinical data on elderly patients. Methods: Patients age ≥65 years undergoing common or major general and vascular operations were selected from the ACS NSQIP 2005-2009 data. Procedures were clinically grouped into 67 categories. Hierarchical logistic modeling was used to calculate risk-adjusted rates for 23 postoperative adverse events, which included death, surgical site infections, and end-organ failure. Adverse events were assigned a weighted value from 1 to 5 according to severity. for each procedure group, the CRS was calculated as the weighted sum of rates for all postoperative events. the median operative time (OT) and length of stay (LOS) for operative cases without adverse events were also assessed. General surgeons were surveyed to rank the procedure groups in order of perceived complexity based operative risk, required technical skill and training, and surgeon effort for performing the operation and providing postoperative care. Comparisons were made between the CRS, OT, LOS, survey results, and work RVU. Results: 205,973 elderly patients met criteria for analysis. the CRS was rescaled from 0 for low risk to 100 for high risk. Operations with the highest scores were open repair of ruptured abdominal aortic aneurysm (100) and open repair of thoracic/thoracoabdominal aneurysm (80); the lowest scorers were open repair of reducible inguinal hernia (1.3) and laparoscopic repair of inguinal hernia (1.4). at the 50th percentile, open repair of non-reducible, recurrent ventral hernia and open cholecystectomy had scores of 16.4 and 18, respectively. Without adverse events, median OT ranged from 38 minutes (open repair of reducible umbilical hernia) to 342 minutes (proximal pancreatectomy); and median LOS ranged from 0 days (outpatient procedures) to 10 days (esophagectomy). the CRS had correlation coefficients of 0.46 with OT and 0.79 with LOS. Work RVU correlated at 0.59 with the CRS. the average rankings from the preliminary surgeon surveys had Spearman correlations of 0.89 with CRS and 0.57 with work RVU. Conclusions: This pilot study demonstrates that clinical data from ACS NSQIP can be used to assess surgical complexity. the CRS provides a single index value, reflecting both severity and likelihood of adverse outcomes that allows objective comparisons of the surgical risk across procedure groups. the work RVU does not strongly correlate with the CRS. the CRS more strongly correlated to the surgeons' rankings of procedures compared to the work RVU. in the next phase, the CRS will be refined based on surveys from a larger group of surgeons.

585 Background: For patients undergoing surgery for cancer, it has been suggested that risk-adjustment with cancer-specific variables is needed when evaluating short-term outcomes. Our objectives were to assess the influence of cancer-related variables on postoperative complications and hospital quality comparisons. Methods: Patients from ACS NSQIP and NCDB who underwent colorectal resection for cancer were linked (2006-2008) to create a dataset containing robust information on comorbidities, complications, and oncologic variables. Three hierarchical models were developed predicting the NSQIP outcome 30-day mortality or any serious morbidity using variables from (1) NSQIP only, (2) NCDB only, and (3) a combined model using NSQIP and NCDB. Models were compared with fit statistics and hospital outlier agreement. Results: From 146 NSQIP hospitals, 11401 patients underwent a colorectal resection for cancer, of which, 1954 (17%) experienced a mortality or serious morbidity event. The first five variables selected in the NCDB-only model were Charlson comorbidity score, neoadjuvant therapy use, T stage, primary payer, and M stage (c-statistic, 0.64; AIC, 9886). The first five variables selected in the NSQIP-only model were ASA class, preop sepsis, albumin, surgical procedure, and COPD (c-statistic, 0.66; AIC, 9787). In the combined model, neoadjuvant therapy use was the only cancer-specific variable selected in the top five. The remaining variables were ASA class, preop sepsis, albumin, and wound class (c-statistic, 0.67; AIC, 9455). At the hospital-level, the NCDB-only model identified three high outliers (worse than expected) and one low outlier (better than expected). Both the NSQIP-only and combined models identified the same four high and two low outlying hospitals (kappa: 1.0), which agreed marginally with the NCDB-only model (kappa: 0.59). Conclusions: Addition of cancer-specific variables to NSQIP models slightly improved model fit; however, hospital outcome comparisons were identical. For patients with colorectal cancer undergoing resection, cancer-related factors have limited predictive ability for short-term outcomes and did not influence hospital quality comparisons.

78 Background: Consensus guidelines recommend neoadjuvant chemo- or chemoradiation therapy as the preferred treatment for locally advanced esophageal adenocarcinoma; however, it is unknown if this recommendation has been widely adopted in the U.S. Our objective was to examine esophageal cancer multimodal therapy and identify factors associated with the use of neoadjuvant therapy. Methods: From the National Cancer Data Base, patients with middle third, lower third and GE junction (GEJ) adenocarcinomas were identified. Patients who were clinical stage I-III and underwent surgical resection were included. Separate logistic regression models were developed to identify predictors of neoadjuvant therapy utilization and outcomes. Results: From 1998 to 2007, 8,051 patients underwent surgical resection for esophageal cancer: 16.3% stage I, 45.0% stage II and 38.7% stage III. For stage II/III tumors, neoadjuvant use increased (49.0% to 77.8%, p<0.001). After adjustment, factors associated with underuse of neoadjuvant therapy in stage II/III patients were older age, Black or Hispanic ethnicity, more severe comorbidities, tumor location (GEJ and middle vs. lower third), tumor size ≥ 2cm, stage II (vs. III) and geographic region. Stage II/III patients not receiving neoadjuvant had an over two fold increased risk of positive lymph nodes (OR 2.14. 95% CI 1.79 – 2.55, p<0.001). In addition, the positive surgical margin rate increased almost three fold (OR 2.80 95% CI 2.17-3.62, p<0.001) but 30-day postoperative mortality risk was not significantly affected (OR 1.50 95% CI 0.94-2.39; p=0.090). For stage I patients, neoadjuvant therapy decreased over time (38.0% to 11.4%, p<0.001). The overuse of neoadjuvant therapy was associated with higher tumor grade, larger tumor size, and low surgical case volume (all p<0.05). Conclusions: The adoption of neoadjuvant therapy has increased in the past decade; however, opportunity exists to improve guideline treatment for locally advanced esophageal cancer. Registry-based feedback to individual hospitals, such as benchmark comparison tools, could help institutions provide care in concordance with national guidelines. No significant financial relationships to disclose.