Historically, exception points for hepatocellular carcinoma (HCC) led to higher transplant rates and lower waitlist mortality for HCC candidates compared to non‐HCC candidates. As of October 2015, HCC candidates must wait 6 months after initial application to obtain exception points; the impact of this policy remains unstudied. Using 2013‐2017 SRTR data, we identified 39 350 adult, first‐time, active waitlist candidates and compared deceased donor liver transplant (DDLT) rates and waitlist mortality/dropout for HCC versus non‐HCC candidates before (October 8, 2013‐October 7, 2015, prepolicy) and after (October 8, 2015‐October 7, 2017, postpolicy) the policy change using Cox and competing risks regression, respectively. Compared to non‐HCC candidates with the same calculated MELD, HCC candidates had a 3.6‐fold higher rate of DDLT prepolicy (aHR = _3.49 3.69 _3.89) and a 2.2‐fold higher rate of DDLT postpolicy (aHR = _2.09 2.21 _2.34). Compared to non‐HCC candidates with the same allocation priority, HCC candidates had a 37% lower risk of waitlist mortality/dropout prepolicy (asHR = _0.54 0.63 _0.73) and a comparable risk of mortality/dropout postpolicy (asHR = _0.81 0.95 _1.11). Following the policy change, the DDLT advantage for HCC candidates remained, albeit dramatically attenuated, without any substantial increase in waitlist mortality/dropout. In the context of sickest‐first liver allocation, the revised policy seems to have established allocation equity for HCC and non‐HCC candidates.

The Kidney Allocation System fundamentally altered kidney allocation, causing a substantial increase in regional and national sharing that we hypothesized might impact geographic disparities. We measured geographic disparity in deceased donor kidney transplant (DDKT) rate under KAS (6/1/2015-12/1/2016), and compared that with pre-KAS (6/1/2013-12/3/2014). We modeled DSA-level DDKT rates with multilevel Poisson regression, adjusting for allocation factors under KAS. Using the model we calculated a novel, improved metric of geographic disparity: the median incidence rate ratio (MIRR) of transplant rate, a measure of DSA-level variation that accounts for patient casemix and is robust to outlier values. Under KAS, MIRR was _1.751.81_1.86 for adults, meaning that similar candidates across different DSAs have a median 1.81-fold difference in DDKT rate. The impact of geography was greater than the impact of factors emphasized by KAS: having an EPTS score ≤20% was associated with a 1.40-fold increase (IRR = _1.351.40_1.45, P < .01) and a three-year dialysis vintage was associated with a 1.57-fold increase (IRR = _1.561.57_1.59, P < .001) in transplant rate. For pediatric candidates, MIRR was even more pronounced, at _1.661.92_2.27. There was no change in geographic disparities with KAS (P = .3). Despite extensive changes to kidney allocation under KAS, geography remains a primary determinant of access to DDKT.

Surgical patients increasingly have more comorbidities and are of an older age, complicating surgical decision-making in emergent situations. Little is known about surgeons' perceptions of shared decision-making in these settings. Twenty semi-structured interviews were conducted with practicing surgeons at 2 large academic medical centers. Thirteen questions and 2 case vignettes were used to assess perceptions of decision-making, considerations when deciding whether to offer to operate, and communication patterns with patients and families. Thematic analysis revealed 6 major themes: responsibility for the decision to operate, perceived futility, surgeon judgment, surgeon introspection, pressure to operate, and costs of the operation. Perceived futility was universally considered a contraindication to surgical intervention. However, the challenge of defining futility led participants to emphasize the importance of patients' self-determined risk-to-benefit analysis when considering surgical intervention. More experienced surgeons reported greater comfort with communicating to patients that a condition was not amenable to an operation and reserved the right to refuse to operate. Due to external pressures and uncertainty, some providers err on the side of operative intervention, despite suspected futility. Greater experience allows surgeons to withstand external pressures, be confident in their assessments of perceived futility, and guide patients and their families away from additional interventions.

Background.: Social media platforms are increasingly used in surgery and have shown promise as effective tools to promote deceased donation and expand living donor transplantation. There is a growing need to understand how social media-driven communication is perceived by providers in the field of transplantation. Methods.: We surveyed 299 members of the American Society of Transplant Surgeons about their use of, attitudes toward, and perceptions of social media and analyzed relationships between responses and participant characteristics. Results.: Respondents used social media to communicate with: family and friends (76%), surgeons (59%), transplant professionals (57%), transplant recipients (21%), living donors (16%), and waitlisted candidates (15%). Most respondents (83%) reported using social media for at least 1 purpose. Although most (61%) supported sharing information with transplant recipients via social media, 42% believed it should not be used to facilitate living donor-recipient matching. Younger age (P = 0.02) and fewer years of experience in the field of transplantation (P = 0.03) were associated with stronger belief that social media can be influential in living organ donation. Respondents at transplant centers with higher reported use of social media had more favorable views about sharing information with transplant recipients (P < 0.01), increasing awareness about deceased organ donation (P < 0.01), and advertising for transplant centers (P < 0.01). Individual characteristics influence opinions about the role and clinical usefulness of social media. Conclusions.: Transplant center involvement and support for social media may influence clinician perceptions and practices. Increasing use of social media among transplant professionals may provide an opportunity to deliver high-quality information to patients.

Liposarcomas of the spermatic cord, a rare cause of an inguinal mass, may closely mimic inguinal hernias on clinical examination. However, these tumors require a different surgical approach and treatment plan; therefore, intraoperative diagnosis might complicate patient management. We report the case of a 63-year-old man who presented with a mobile mass in the inguinal canal consistent with an inguinal hernia. The patient was subsequently diagnosed with a liposarcoma of the spermatic cord and successfully treated with extensive local resection, including radical orchiectomy and en bloc resection of the mass and associated cord structures. No adjuvant therapy was deemed necessary, and the patient remained asymptomatic and disease-free 10 years after surgery. The details of this case are presented, along with a review and discussion of the currently available data regarding the diagnosis and management of this challenging condition.