COVID-19 is a pandemic which has affected almost every aspect of our life since starting globally in November 2019. Given the rapidity of spread and inadequate time to prepare for record numbers of sick patients, our surgical community faces an unforeseen challenge. SAGES is committed to the protection and care of patients, their surgeons and staff, and all who are served by the medical community at large. This includes physical health, mental health, and well-being of all involved. The fear of the unknown ahead can be paralyzing. International news media have chronicled the unthinkable situations that physicians and other health care providers have been thrust into as a result of the COVID-19 pandemic. These situations include making life or death decisions for patients and their families regarding use of limited health care resources. It includes caring for patients with quickly deteriorating conditions and limited treatments available. Until recently, these situations seemed far from home, and now they are in our own hospitals. As the pandemic broadened its reach, the reality that we as surgeons may be joining the front line is real. It may be happening to you now; it may be on the horizon in the coming weeks. In this context, SAGES put together this document addressing concerns on clinician stressors in these times of uncertainty. We chose to focus on the emotional toll of the situation on the clinician, protecting vulnerable persons, reckoning with social isolation, and promoting wellness during this crisis. At the same time, the last part of this document deals with the "light at the end of the tunnel," discussing potential opportunities, lessons learned, and the positives that can come out of this crisis. Keywords Surgeon wellness • COVID-19 • Pandemic well-being • Burnout COVID-19 is a pandemic which has affected almost every aspect of our life since starting globally in November 2019. Given the rapidity of spread and inadequate time to prepare for record numbers of sick patients, our surgical community faces an unforeseen challenge. SAGES is committed to the protection and care of patients, their surgeons and staff, and all who are served by the medical community at large. This

Bariatric surgery patients who receive postoperative blood transfusion are at a significantly increased risk for VTE. The etiology of VTE in those who are transfused is likely multifactorial and possibly related to withholding chemoprophylaxis and the potential of a hypercoagulable state induced by the transfusion. In those who bleed, consideration should be given to reinitiating chemoprophylaxis when safe, extending treatment after discharge, and screening ultrasound.

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Selection of mesh for ventral hernia repair and abdominal wall reconstruction can be challenging. Since the adoption of a tension-free mesh repair, the recurrence rates and outcomes after ventral hernia repair have substantially improved. The market for medical prostheses is constantly changing, with new technology in development attempting to create the ideal mesh for each clinical scenario. Permanent mesh is typically used for clean wounds. The various mesh materials, density, and pore sizes are discussed. In addition, the materials commonly used for contaminated wounds (absorbable synthetic and biologic meshes) are described. The latest literature regarding the use of various mesh materials is reviewed and organized to help make an informed decision regarding the appropriate use of reinforcing material.

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Background The prevalence of super obesity (SO, BMI > 50.0 kg/m 2) and super-super obesity (SSO, BMI > 60 kg/m 2) is increasing. Current data are limited and discrepant on the relationship between SSO and post-bariatric surgery complication risk. We hypothesized there would be increased complications for both laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG) in SSO compared to SO, but the relative risk (RR) would support the use of LSG in SSO patients. Methods Metabolic and Bariatric Surgery Accreditation and Quality Improvement 2016 data were queried for SO and SSO patients undergoing LRYGB or LSG. Thirty-day post-operative complications were calculated. Univariate analyses were performed with a χ 2 or Student's t test. Comparisons between multiple groups were performed using a one-way ANOVA. Statistical significance was defined as p < 0.05. Results A total of 5723 patients with SSO and 24,940 with SO were included for analysis. Patients with SSO had more comorbidities. Patients with SSO had a higher likelihood of complications compared to SO patients (15.2% vs 12.6%, p < 0.0005). SSO patients, and specifically SSO RYGB, were significantly more likely to experience an unplanned intubation, prolonged ventilation, and unplanned ICU admission. Compared to SO LRYGB, the RR for complications in SSO LRYGB and LGS were 1.19 and 0.76 respectively (p < 0.0005). Discussion We found SSO patients had increased 30-day post-operative complications after both LRYGB and LSG compared to SO patients. LSG may be the preferred procedure for this high-risk population.

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