Surgical Endoscopy (2022) 36:1709–1725 and Other Interventional Techniques

https://doi.org/10.1007/s00464-022-09008-0

GUIDELINES

EAES rapid guideline: systematic review, network meta‑analysis,

CINeMA and GRADE assessment, and European consensus on bariatric
surgery–extension 2022
Francesco M. Carrano1 · Angelo Iossa2 · Nicola Di Lorenzo3 · Gianfranco Silecchia2 · Katerina‑Maria Kontouli4 ·
Dimitris Mavridis4,5 · Isaias Alarçon6 · Daniel M. Felsenreich7 · Sergi Sanchez‑Cordero8 · Angelo Di Vincenzo9 ·
M. Carmen Balagué‑Ponz10 · Rachel L. Batterham11,12 · Nicole Bouvy13 · Catalin Copaescu14 · Dror Dicker15 ·
Martin Fried16 · Daniela Godoroja17 · David Goitein18,19 · Jason C. G. Halford20 · Marina Kalogridaki21 ·
Maurizio De Luca22 · Salvador Morales‑Conde6 · Gerhard Prager7 · Andrea Pucci11,12 · Ramon Vilallonga23 ·
Iris Zani24 · Per Olav Vandvik25 · Stavros A. Antoniou26,27   · The EAES Bariatric Surgery Guidelines Group

Received: 11 December 2021 / Accepted: 31 December 2021 / Published online: 20 January 2022
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022

Abstract
Background  The European Association for Endoscopic Surgery Bariatric Guidelines Group identified a gap in bariatric
surgery recommendations with a structured, contextualized consideration of multiple bariatric interventions.
Objective  To provide evidence-informed, transparent and trustworthy recommendations on the use of sleeve gastrectomy,
Roux-en-Y gastric bypass, adjustable gastric banding, gastric plication, biliopancreatic diversion with duodenal switch, one
anastomosis gastric bypass, and single anastomosis duodeno-ileal bypass with sleeve gastrectomy in patients with severe
obesity and metabolic diseases. Only laparoscopic procedures in adults were considered.
Methods  A European interdisciplinary panel including general surgeons, obesity physicians, anesthetists, a psychologist
and a patient representative informed outcome importance and minimal important differences. We conducted a systematic
review and frequentist fixed and random-effects network meta-analysis of randomized-controlled trials (RCTs) using the graph
theory approach for each outcome. We calculated the odds ratio or the (standardized) mean differences with 95% confidence
intervals for binary and continuous outcomes, respectively. We assessed the certainty of evidence using the CINeMA and
GRADE methodologies. We considered the risk/benefit outcomes within a GRADE evidence to decision framework to arrive
at recommendations, which were validated through an anonymous Delphi process of the panel.
Results  We identified 43 records reporting on 24 RCTs. Most network information surrounded sleeve gastrectomy and Roux-
en-Y gastric bypass. Under consideration of the certainty of the evidence and evidence to decision parameters, we suggest
sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass over adjustable gastric banding, biliopancreatic diversion
with duodenal switch and gastric plication for the management of severe obesity and associated metabolic diseases. One
anastomosis gastric bypass and single anastomosis duodeno-ileal bypass with sleeve gastrectomy are suggested as alterna-
tives, although evidence on benefits and harms, and specific selection criteria is limited compared to sleeve gastrectomy and
Roux-en-Y gastric bypass. The guideline, with recommendations, evidence summaries and decision aids in user friendly
formats can also be accessed in MAGICapp: https://​app.​magic​app.​org/#/​guide​line/​Lpv2kE
Conclusions  This rapid guideline provides evidence-informed, pertinent recommendations on the use of bariatric and meta-
bolic surgery for the management of severe obesity and metabolic diseases. The guideline replaces relevant recommendations
published in the EAES Bariatric Guidelines 2020.

Keywords  Bariatric surgery · Metabolic surgery · Severe obesity · EAES · Guidelines · CINeMA · GRADE · AGREE II

Obesity is considered a global disease, affecting both devel-

oped and developing countries [1]. Bariatric and meta-
Francesco M. Carrano and Angelo Iossa share first authorship.
bolic surgery results in weight loss and controls associated
Extended author information available on the last page of the article

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Vol.:(0123456789)

1710
morbidity in a substantial proportion of obese and over-
weight patients.
The European Association for Endoscopic Surgery
(EAES) Bariatric Guidelines 2020, a project endorsed by
the European Chapter of the International Federation for the
Surgery of Obesity (IFSO-EC), the European Association
for the Study of Obesity (EASO) and the European Soci-
ety for Perioperative Care of the Obese Patient (ESPCOP),
provided evidence-informed recommendations on the man-
agement of patients undergoing bariatric surgery [2]. This
guideline used standard GRADE methodology with pairwise
meta-analyses and conceptual considerations between com-
peting interventions. In view of the multitude of manage-
ment options, the guideline panel highlighted the need to
compare multiple bariatric interventions, rather than provide
recommendations for head-to-head competing interventions.
Most trials, however, reported on pairwise comparisons,
thereby not allowing assessment of the safety and efficacy
of multiple interventions within the same analysis model.
This limitation is addressed by network meta-analytical tech-
niques. Network meta-analysis (NMA) extends the princi-
ples of meta-analysis to the comparison of multiple treat-
ments in a single analysis. This is achieved by combining
both direct and indirect evidence. Direct evidence refers to
the evidence obtained from pairwise comparisons; indirect
evidence refers to the evidence obtained through one or more
common comparators [3]. Their combination is defined as
mixed evidence.
Further to the limitations of pairwise comparisons, a
number of follow-up and new studies have been published
since the development of the previous guidelines, and
another study has been retracted [4].
This project is an extension of the EAES Bariatric Guide-
lines 2020 with the aim to provide up-to-date evidence-
informed recommendations on the safest and most effective
management options among bariatric/metabolic operations.
Objective
The objective of this rapid guideline was to develop reliable,
trustworthy, pertinent, evidence-informed recommendations
on the use of different bariatric procedures in patients with
severe obesity and metabolic diseases.
Methods
This rapid guideline follows AGREE-II, GRADE, Institute
of Medicine, Guidelines International Network (G-I-N) and
Cochrane Rapid Reviews Methods Group development and
reporting standards [5–9]. GRADE guidance published in a
series of articles in the Journal of Clinical Epidemiology was
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Surgical Endoscopy (2022) 36:1709–1725
consulted for up-to-date information. Importantly, the devel-
opment of this guideline was informed by the GRADE meth-
odology to appraise the certainty of the evidence from a
NMA, the Confidence in Network Meta-Analysis (CINeMA)
methodology, and the GRADE evidence to decision frame-
work to choose from multiple interventions [10–13]. This
process was facilitated by the use of MAGICapp, an online
authoring and publication platform.
Steering group
The steering group consisted of two junior members (AI,
FMC) who acted as coordinators, supported by the sen-
ior coordinators (GS, NDL), who are bariatric surgeons;
a certified guideline methodologist with vast experience
in evidence outreach, synthesis, assessment and guideline
development, (chair and supervisor, SAA); biostatisti-
cians (KMK, DM); and a GRADE external auditor (POV).
All members of the steering group disclosed no conflicts,
direct or indirect [14].
Guideline panel
The guideline panel consisted of 9 general surgeons, 3 obe-
sity physicians, 2 anesthetists, a psychologist and a patient
representative. The patient representative was identified
through the EASO Patient Task Force. Panel members
watched a short video tutorial outlining the guideline devel-
opment methodology. The composition of panel members
aimed to be representative of different parts of Europe, both
genders, different age groups, and both academic and non-
academic practice. The majority of panel members disclosed
no direct nor indirect conflicts [14]. Some panel members
disclosed indirect conflicts as authors of publications on a
topic that expresses an opinion on the effectiveness of an
intervention, or because they were performing research on
a topic that could be affected by a recommendation of this
guideline. These members were not involved in the deci-
sions on the strength, the direction and the wording of the
respective recommendations, but they were consulted in the
development of the respective evidence to decision frame-
works, as per GRADE and G-I-N guidance.
Health question
Which bariatric procedure should be used in adult patients
with severe obesity and metabolic disease, among sleeve
gastrectomy, Roux-en-Y gastric bypass, adjustable gastric
banding, gastric plication, biliopancreatic diversion with
duodenal switch, one anastomosis gastric bypass, single
anastomosis duodeno-ileal bypass with sleeve gastrectomy?
Surgical Endoscopy (2022) 36:1709–1725 1711
Protocol
A protocol was developed a priori by the steering group [15].
The protocol draft was made publicly available through the
EAES website and EAES members were invited through
various channels to comment on the content. The guideline
questions and outcomes of interest were refined in collabora-
tion with the panel members. There were no additional com-
ments from EAES members. Amendments to the protocol
with justifications are provided below.
Rating the importance of outcomes
The importance of outcomes was rated by panel members
using the GRADE scale [16]. The classification of outcomes
into each of the three categories (not important, important,
critical) was made by the steering group under consideration
of panel members’ ratings available online [14].
We considered the importance of outcomes as follows:
1. Percentage of excess weight loss (EWL %) at
5 years: critical
2. Major complications (30-day complications Clavien-
Dindo ≥ 3): critical
3. Minor complications (30-day complications Clavien-
Dindo ≤ 2): important
4. Mortality (30-day or in-hospital): critical
5. Quality of life: critical
6. Improvement of diabetes: critical
7. Improvement of sleep apnea: important
8. Improvement of cholesterol levels: important
9. Improvement of hypertension: important
10. Improvement of NAFDL/NASH: important
11. Improvement of osteoarthritis: important
12. Reoperation (including revisional operation): impor-
tant
Setting minimal important differences
The evidence to decision framework was set within a fully
contextualized approach [17]. An anonymous web-based
survey of panel members was performed to define minimal
important differences. The results of the survey are available
online [14].
Under consideration of panel's responses, the following
minimal important differences were set:
1. EWL % at 5 years: 20%
2. Major complications (30-day complications Clavien-
Dindo ≥ 3): 25 per 1000
3. Minor complications (30-day complications Clavien-
Dindo ≤ 2): 50 per 1000
4. Mortality (30-day or in-hospital): 5 per 1000
5. Quality of life: 0.2/0.5 standard deviations (small/mod-
erate difference)
6. Improvement of diabetes: 25 per 1000
7. Improvement of sleep apnea: 50 per 1000
8. Improvement of cholesterol levels: 25 per 1000
9. Improvement of hypertension: 25 per 1000
10. Improvement of NAFDL/NASH: 25 per 1000
11. Improvement of osteoarthritis: 25 per 1000
12. Reoperation (including revisional operation): 25 per
1000
Search strategy
A search strategy with no language or date restrictions was
developed and the databases of Pubmed and OpenGrey were
interrogated on April 4, 2021. The search syntax is available
online [14].
Study selection
Study selection was performed by an ad hoc evidence out-
reach team (MF, IA, SSC, ADV). First-level and second-
level screening were performed by 4 reviewers (MF, IA,
SSC, ADV), each pair of reviewers screening a proportion
of records, using the platform Rayyan [18]. Both reviewers
were blinded to the other reviewer’s judgement and, after
unblinding, disagreements were resolved through arbitration
by the senior author. Only randomized-controlled trials were
included. Overarching inclusion criterion was body mass
index (BMI) ≥ 35 kg/m2 or ≥ 30 kg/m2 with associated mor-
bidity. Laparoscopic operations only were considered and we
included records published from 2011 onwards to capture
the most pertinent evidence, incorporating up-to-date prac-
tice. Detailed reasons for exclusion can be found online [14].
Data extraction
Outcome data were extracted by the same 4 reviewers,
each reviewer extracting data from a proportion of records.
All extracted data were cross checked by the senior author
(SAA). Risk of bias assessments were performed by the
senior author (SAA). The data extraction spreadsheet and
detailed risk of bias assessments per outcome or group of
outcomes with justifications are available online also for
third-party use under the Creative Commons license, after
approval by the senior author [14].
Particular care was taken to avoid double-counting of data
from different reports of the same trial, by cross checking the
trial registration number, country and institution, the authors'
names, years of patient recruitment, sample size, etc. It was
not clear whether three publications reported on the same
population [19–21], which was confirmed by a member of
the study author team after email communication.
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We used PlotDigitizer (http://​plotd​igiti​zer.​sourc​eforge.​
net) to retrieve data from graphs, when absolute values were
not provided in the study reports [22–24].
Risk of bias assessment
RoB-2 was used for risk of bias assessment [25]. Risk of bias
assessment and visual summarization were performed with
the RoB-2 tool and the respective Excel application [25].
Statistical analysis
We conducted a frequentist fixed and random-effects net-
work meta-analysis using the graph theory [26] approach for
each outcome (EWL % at 5 years, 30-day or in-hospital com-
plications Clavien-Dindo ≥ 3, 30-day or in-hospital compli-
cations Clavien-Dindo ≤ 2, 30-day or in-hospital mortality,
quality of life, improvement of diabetes, improvement of
sleep apnea, improvement of cholesterol levels, improvement
of hypertension, improvement of NAFDL/NASH, improve-
ment of osteoarthritis, and reoperation, including revisional
operation) in R version 4.0.6 with the netmeta package
[27]. For dichotomous outcomes, we estimated summary
odds ratios (ORs) with their 95% confidence intervals (CI).
We had two continuous outcomes, EWL % and quality of
life. For EWL %, we estimated mean differences and their
95% CI, but for quality of life, we reported standardized
mean differences, with their 95% CI, because different scales
were reported among studies. All relative effects estimates
and their corresponding 95% CI were summarized in league
tables, available in the Appendix. We also presented the 95%
prediction intervals for all outcomes. We ranked all treat-
ments in each outcome using p-scores [28]. P-scores assume
values from zero to one; the larger the p-score the better the
treatment. NMA makes two basic assumptions, the assump-
tion of transitivity and of consistency [29]. The assumption
of transitivity, which is conceptual, refers to all effect modi-
fiers being similarly distributed across studies. The statisti-
cal manifestation of transitivity is that of consistency. The
assumption of consistency refers to the agreement between
direct and indirect evidence. We evaluated the inconsistency
assumption model using the design-by-treatment model [30]
for the entire network and we used the node-splitting method
to detect local inconsistency [31]. We assessed for potential
reporting bias via comparison-adjusted funnel plots, which
is an extension of the funnel plot in the pairwise meta-
analysis [32]. To calculate absolute differences for evidence
tables, we calculated baseline risk or effect using propor-
tion meta-analysis of baseline values provided by each study.
Baseline effect or risk estimates are available online [14].
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Surgical Endoscopy (2022) 36:1709–1725
Assessment of the certainty of evidence
We constructed GRADE evidence profiles of certainty for
each outcome and for each pairwise comparison separately
using MAGICapp. The certainty of evidence is determined
by the risk of bias across studies, incoherence, indirect-
ness, imprecision, publication bias and other parameters
[33]. Minimal important differences determined in advance
through a survey of panel members were used to inform
judgements on precision and coherence.
We used the CINeMA software to summarize risk of
bias according to the contribution of each study to the net-
work for the respective outcome [13, 34]. The overall risk
of (within study) bias was based upon the highest proportion
of risk of bias contributed to the network, as per CINeMA
methodology [13]. Judgements on publication (reporting)
bias were based on comparison-adjusted funnel plots. Judge-
ments on indirectness were based on conceptual differences
between the study populations, settings and interventions
(which was judged as low risk across outcomes, except when
the network for a specific outcome was considered to provide
short duration of follow-up), and the presence of direct evi-
dence; if only indirect evidence was present (which does not
allow for assessment of inconsistency), we downgraded the
evidence certainty by one level. Heterogeneity judgements
were based upon statistical calculations of heterogeneity
and consistency. If substantial heterogeneity or inconsist-
ency were found, we downgraded the certainty in the evi-
dence by one or two levels. Judgements on imprecision were
based upon minimal important differences that were set by
majority voting of the guideline panel in advance, according
to principles of a fully contextualized approach (minimal
important differences for each outcome were based upon
the assumption that each outcome is the only outcome of
interest) [17].
For each outcome, we stratified interventions by certainty
(moderate-to-high or low-to-very low). We then grouped
interventions within each stratum into 3 groups according to
their statistical ranking: among the best, inferior to the best/
better than the worst, and among the worst. The classified
rankings were considered by panel members as complemen-
tary to the GRADE evidence tables. This process facilitates
assessment of both the certainty of the evidence on each
intervention along with their ranking [35]. Stratified ranking
tables are available online [14].
Evidence to decision framework and development
of recommendations
The guideline panel reviewed the evidence tables and the
stratified rankings. In an anonymous survey, panel members
were asked whether they consider that:
Surgical Endoscopy (2022) 36:1709–1725 1713

– There is variability in patients' values and preferences
with regard to different interventions
– There are any issues with cost or the use of resources
related to the use of the interventions
– Any interventions have different effect on equity
– The preferred interventions are acceptable to the target
population and its implementors
– There are any issues with feasibility of implementing a
recommendation in favor of any of the interventions.
If a panel member provided a positive response, they were
asked to rank the interventions from best to worst in the
respective evidence to decision domain.
Panel members were provided with the detailed responses
and mean ranks, and they participated in an online Delphi
process to formulate the recommendation. A draft of the
recommendation was developed by the steering group,
and panel members were invited to anonymously propose
modifications.
Amendments to the protocol
We searched Pubmed instead of MEDLINE, because it
allows more precise search of RCTs using the Cochrane
Highly Sensitive Search. We did not interrogate EMBASE
due to limited time resources. Based on previous vast experi-
ence with systematic reviews in the field of surgery, we do
not consider this to have introduced publication bias.
We planned to perform subgroup analyses of patients
with type II diabetes mellitus, however the evidence was
limited with sparse network outcomes, and the effect esti-
mates were imprecise, thus not reaching meaningful conclu-
sions. Complete datasets and statistical results are available
upon reasonable request.
Instead of GRADE evidence tables for NMA [12], we
applied the process described by Flórez et al. [35], which
entails classifying ranked interventions by certainty and
constructing stratified ranking tables. We found this process
very useful, because it facilitated assessment of the certainty
of the evidence on each intervention along with their rank-
ing. Panel members were made specifically aware that they
should not rely only on the ranking of interventions, but also
on pairwise effect estimates [36].
inconsistency statistics and funnel plots are provided in the
Appendix. The network plot for the outcome EWL % at
5 years is presented in Fig. 1.
No substantial intransitivity was identified across studies,
with regard to interventions, patient characteristics, methods
of measurement, duration and modality of follow-up. Sta-
tistical results were not suggestive of inconsistency in most
analyses (see Online Appendix). Evidence tables for the
comparisons among sleeve gastrectomy, RYGB and OAGB
are available in Tables 1, 2 and 3.
Survey results of panel members on evidence to decision
framework domains and Delphi responses for formulation
of the recommendation are available online [14]. The rec-
ommendation was finalized after 2 Delphi rounds, with a
92% agreement and one neutral vote. Evidence tables for all
comparisons are available in the Online Appendix.
Recommendation
We suggest sleeve gastrectomy or laparoscopic Roux-en-
Y gastric bypass over adjustable gastric banding, bili-
opancreatic diversion with duodenal switch and gastric
plication for the management of severe obesity and asso-
ciated metabolic diseases.
One anastomosis gastric bypass and single anastomo-
sis duodeno-ileal bypass with sleeve gastrectomy are sug-
gested as alternatives, although evidence on benefits and
harms, and specific selection criteria is limited compared
to sleeve gastrectomy and Roux-en-Y gastric bypass.

Results

We screened 2305 records and 65 full text articles, out of

which 43 records reporting on 24 RCTs met the eligibil-
ity criteria [19–24, 37–73]. Detailed reasons for exclusion
of each record and risk of bias assessments with justifi-
cation are available online [14]. The study selection flow
chart, risk of bias summaries, network plots, league tables, Fig. 1  Network plot for the outcome EWL % at 5 years

13


Table 1  Evidence table for the comparison sleeve gastrectomy (SG) versus Roux-en-Y gastric bypass (RYGB)
1714

Outcome Study results and measurements Absolute effect estimates Certainty of the Evidence Plain language summary
Timeframe (Quality of evidence)

13
RYGB SG

Major ­morbidity1 Odds Ratio: 0.5 72 37 Moderate Sleeve gastrectomy is probably associ-
30 days (CI 95% 0.25–1.0) per 1000 per 1000 Due to serious ­imprecision2 ated with a slightly decreased risk of
Difference: 35 fewer per 1000 major morbidity compared to RYGB
(CI 95% 53 fewer–0 fewer)
Minor ­morbidity3 Odds Ratio: 0.68 122 86 Very low We are uncertain about the compara-
30 days (CI 95% 0.38–1.21) per 1000 per 1000 Due to serious inconsistency, serious tive effect of sleeve gastrectomy vs
Difference: 36 fewer per 1000 imprecision and serious publica- RYGB on minor morbidity
(CI 95% 72 fewer–22 more) tion ­bias4
Mortality5 Odds Ratio: 0.34 14 5 Very low We are uncertain about the compara-
30 days (CI 95% 0.01–8.33) per 1000 per 1000 Due to serious risk of bias and very tive effect of sleeve gastrectomy vs
Difference: 9 fewer per 1000 serious ­imprecision6 RYGB on mortality
(CI 95% 14 fewer–92 more)
Improvement of d­ iabetes7 Odds Ratio: 0.55 777 657 Low Sleeve gastrectomy may be slightly
5 years (CI 95% 0.34–0.88) per 1000 per 1000 Due to serious risk of bias and seri- less effective than RYGB in improve-
Difference: 120 fewer per 1000 ous ­inconsistency8 ment of diabetes
(CI 95% 235 fewer–23 fewer)
Improvement of sleep apnea Odds Ratio: 1.12 956 961 Very low We are uncertain about the compara-
5 years (CI 95% 0.15–8.33) per 1000 per 1000 Due to serious risk of bias and very tive effect of sleeve gastrectomy vs
Difference: 5 more per 1000 serious ­imprecision9 RYGB on sleep apnea
(CI 95% 191 fewer–39 more)
Improvement of c­ holesterol10 Odds Ratio: 0.59 763 655 Low Sleeve gastrectomy may be less effec-
5 years (CI 95% 0.29–1.22) per 1000 per 1000 Due to serious risk of bias and seri- tive than RYGB in improvement of
Difference: 108 fewer per 1000 ous ­imprecision11 cholesterol levels
(CI 95% 280 fewer–34 more)
Improvement of h­ ypertension12 Odds Ratio: 0.61 796 704 Low Sleeve gastrectomy may be slightly
5 years (CI 95% 0.38–1.0) per 1000 per 1000 Due to serious risk of bias and seri- less effective than RYGB in the
Difference: 92 fewer per 1000 ous ­imprecision13 improvement of hypertension
(CI 95% 199 fewer–0 fewer)
Improvement of NAFDL/NASH Odds Ratio: 0.11 143 18 Very low We are uncertain about the compara-
5 years (CI 95% 0.02–0.51) per 1000 per 1000 Due to very serious imprecision and tive effect of sleeve gastrectomy vs
Difference: 125 fewer per 1000 serious ­indirectness14 RYGB on NAFDL/NASH
(CI 95% 140 fewer–65 fewer)
Improvement of osteoarthritis Odds Ratio: 3.7 845 953 Very low We are uncertain about the compara-
5 years (CI 95% 1.15–12.5) per 1000 per 1000 Due to serious risk of bias, seri- tive effect of sleeve gastrectomy vs
Difference: 108 more per 1000 ous indirectness and serious RYGB on osteoarthritis
(CI 95% 17 more–141 more) ­imprecision15
Reoperation16 Odds Ratio: 0.59 112 69 Low Sleeve gastrectomy may be associated
5 years (CI 95% 0.36–0.97) per 1000 per 1000 Due to serious risk of bias and seri- with a slightly lower risk of reopera-
Difference: 43 fewer per 1000 ous ­imprecision17 tion compared to RYGB
Surgical Endoscopy (2022) 36:1709–1725

(CI 95% 69 fewer–3 fewer)

 Table 1  (continued)
Outcome Study results and measurements Absolute effect estimates Certainty of the Evidence Plain language summary
Timeframe (Quality of evidence)
RYGB SG

Excess weight loss Measured by: % 65.62 56.84 Low Sleeve gastrectomy may have little
5 years Scale:–High better Mean Mean Due to serious risk of bias and seri- or no clinically important effect
ous publication b­ ias18 on excess weight loss compared to
Difference: MD 6.13 lower RYGB
(CI 95% 1.40 lower–10.86 lower)
Quality of life Measured by: SD 0.79 0.73 Very low Sleeve gastrectomy may have little
5 years Scale:–High better Mean Mean Due to serious risk of bias and very or no clinically important effect on
Difference: SMD 0.09 lower serious ­inconsistency19 quality of life compared to RYGB
Surgical Endoscopy (2022) 36:1709–1725

(CI 95% 0.07 lower–0.24 higher)

1
 30-day or in-hospital complications Clavien-Dindo ≥ 3
2
 Imprecision: serious. Wide confidence intervals crossing panel-set minimal important difference
3
 30-day or in-hospital complications Clavien-Dindo ≥ 3
4
 Inconsistency: serious. The magnitude of statistical heterogeneity was high; no evidence of inconsistency.; Imprecision: serious. Wide confidence intervals, crossing panel-set minimal
important difference.; Publication bias: serious. Asymmetrical funnel plot
5
 30-day or in-hospital mortality
6
 Risk of Bias: serious. Imprecision: very serious. Wide confidence intervals crossing panel-set minimal important difference, low number of patients
7
 Cessation or decrease of diabetes medication, or decrease in HbA1c levels
8
 Risk of Bias: serious. Inconsistency: serious. The magnitude of statistical heterogeneity was high and there was evidence of incoherence
9
 Risk of Bias: serious. Imprecision: very serious. Wide confidence intervals crossing panel-set minimal important difference, low number of patients
10
 Decrease of cholesterol levels or cessation of medication
11
 Risk of Bias: serious. Imprecision: serious. Wide confidence intervals crossing panel-set minimal important difference
12
 Decrease of blood pressure levels or cessation of medication
13
 Risk of Bias: serious. Imprecision: serious. Wide confidence intervals crossing panel-set minimal important difference
14
 Indirectness: serious. Short follow-up; Imprecision: very serious. Low number of patients
15
 Risk of Bias: serious. Indirectness: serious. Short follow-up; Imprecision: serious. Wide confidence intervals crossing panel-set minimal important difference
16
 Reoperation for any reason, including revisional operation
17
 Risk of Bias: serious. Imprecision: serious
18
 Risk of Bias: serious. primarily due to missing outcome data; Publication bias: serious. Asymmetrical funnel plot
19
 Risk of Bias: serious. Inconsistency: very serious. Due to evidence of very serious incoherence and serious heterogeneity

13
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Table 2  Evidence table for the comparison sleeve gastrectomy (SG) versus one anastomosis gastric bypass (OAGB)
1716

Outcome Study results and measurements Absolute effect estimates Certainty of the Evidence Plain language summary
Timeframe (Quality of evidence)
OAGB SG

13
Major ­morbidity1 Odds Ratio: 0.29 160 52 Very low We are uncertain about the comparative
30 days (CI 95% 0.06–1.45) per 1000 per 1000 Due to serious risk of bias, serious incon- effect of sleeve gastrectomy vs OAGB on
Difference: 108 fewer per 1000 sistency and serious i­mprecision2 major morbidity
(CI 95% 149 fewer–56 more)
Minor ­morbidity3 Odds Ratio: 0.61 57 36 Very low We are uncertain about the comparative
30 days (CI 95% 0.06–6.25) per 1000 per 1000 Due to serious risk of bias, serious pub- effect of sleeve gastrectomy vs OAGB on
Difference: 21 fewer per 1000 lication bias, serious inconsistency and minor morbidity
(CI 95% 53 fewer–217 more) serious ­imprecision4
Improvement of d­ iabetes5 Odds Ratio: 0.32 438 200 Very low We are uncertain about the comparative
5 years (CI 95% 0.11–0.94) per 1000 per 1000 Due to very serious risk of bias, serious effect of sleeve gastrectomy vs OAGB
Difference: 238 fewer per 1000 inconsistency and serious i­mprecision6 on diabetes
(CI 95% 359 fewer–15 fewer)
Improvement of sleep apnea Odds Ratio: 1.52 877 916 Very low We are uncertain about the comparative
5 years (CI 95% 0.51–4.55) per 1000 per 1000 Due to serious risk of bias, serious incon- effect of sleeve gastrectomy vs OAGB on
Difference: 39 more per 1000 sistency and serious ­imprecision7 sleep apnea
(CI 95% 93 fewer–93 more)
Improvement of c­ holesterol8 Odds Ratio: 1.47 783 841 Very low We are uncertain about the comparative
5 years (CI 95% 0.15–14.3) per 1000 per 1000 Due to serious risk of bias and very seri- effect of sleeve gastrectomy vs OAGB on
Difference: 58 more per 1000 ous ­imprecision9 cholesterol levels
(CI 95% 432 fewer–198 more)
Improvement of h­ ypertension10 Odds Ratio: 0.34 918 792 Very low We are uncertain about the comparative
5 years (CI 95% 0.14–0.86) per 1000 per 1000 Due to very serious risk of bias, serious effect of sleeve gastrectomy vs OAGB on
Difference: 126 fewer per 1000 inconsistency and serious i­mprecision11 hypertension
(CI 95% 308 fewer–12 fewer)
Improvement of osteoarthritis Odds Ratio: 1.06 872 878 Very low We are uncertain about the comparative
5 years (CI 95% 0.45–2.5) per 1000 per 1000 Due to serious risk of bias and very seri- effect of sleeve gastrectomy vs OAGB on
Difference: 6 more per 1000 ous ­imprecision12 osteoarthritis
(CI 95% 118 fewer–73 more)
Reoperation13 Odds Ratio: 0.6 56 34 Very low We are uncertain about the comparative
5 years (CI 95% 0.14–2.63) per 1000 per 1000 Due to very serious risk of bias, serious effect of sleeve gastrectomy vs OAGB on
Difference: 22 fewer per 1000 inconsistency and serious i­mprecision14 reoperation
(CI 95% 48 fewer–79 more)
Excess weight loss Measured by: % 71.37 56.84 Very low We are uncertain about the comparative
5 years Scale:–High better Mean Mean Due to very serious risk of bias and seri- effect of sleeve gastrectomy vs OAGB on
Difference: MD 10.88 higher ous ­inconsistency15 excess weight loss
(CI 95% 3.68 higher–18.08 higher)
Surgical Endoscopy (2022) 36:1709–1725
 Table 2  (continued)

Outcome Study results and measurements Absolute effect estimates Certainty of the Evidence Plain language summary
Timeframe (Quality of evidence)
OAGB SG
Quality of life Measured by: SD 0.89 0.73 Very low We are uncertain about the comparative
5 years Scale:–High better Mean Mean Due to very serious risk of bias and very effect of sleeve gastrectomy vs OAGB on
Difference: SMD 1.00 higher serious ­inconsistency16 quality of life
(CI 95% 0.65 higher–1.34 higher)
1
 30-day or in-hospital complications Clavien-Dindo ≥ 3
2
 Risk of Bias: serious. Inconsistency: serious. No direct evidence; Imprecision: serious. Wide confidence intervals crossing panel-set minimal important difference
3
 30-day or in-hospital complications Clavien-Dindo ≥ 3
4
Surgical Endoscopy (2022) 36:1709–1725

 Risk of Bias: serious. Inconsistency: serious. No direct evidence; Imprecision: serious. Wide confidence intervals crossing panel-set minimal important difference; Publication bias: seri-
ous. Asymmetrical funnel plot
5
 Cessation or decrease of diabetes medication, or decrease in HbA1c levels
6
 Risk of Bias: very serious. Inconsistency: serious. The magnitude of statistical heterogeneity was high and there was evidence of incoherence; Imprecision: serious. Wide confidence inter-
vals crossing panel-set minimal important difference
7
 Risk of Bias: serious. Inconsistency: serious. The magnitude of statistical heterogeneity was high; Imprecision: serious. Wide confidence intervals crossing panel-set minimal important dif-
ference
8
 Decrease of cholesterol levels or cessation of medication
9
 Risk of Bias: serious. Imprecision: very serious. Wide confidence intervals crossing panel-set minimal important difference
10
 Decrease of blood pressure levels or cessation of medication
11
 Risk of Bias: very serious. Inconsistency: serious. The magnitude of statistical heterogeneity was high; Imprecision: serious. Wide confidence intervals crossing panel-set minimal impor-
tant difference
12
 Risk of Bias: serious. Imprecision: very serious. Wide confidence intervals crossing panel-set minimal important difference
13
 Reoperation for any reason, including revisional operation
14
 Risk of Bias: very serious. Inconsistency: serious. The magnitude of statistical heterogeneity was high; Imprecision: serious. Wide confidence intervals crossing panel-set minimal impor-
tant difference
15
 Risk of Bias: very serious. Inconsistency: serious. The magnitude of statistical heterogeneity was high;
16
 Risk of Bias: very serious. Inconsistency: very serious. Due to evidence of very serious incoherence

13
1717


Table 3  Evidence table for the comparison Roux-en-Y gastric bypass (RYGB) versus one anastomosis gastric bypass (OAGB)
1718

Outcome Study results and measurements Absolute effect estimates Certainty of the Evidence Plain language summary
Timeframe (Quality of evidence)

13
OAGB LRYGB

Major ­morbidity1 Odds Ratio: 0.59 160 101 Very low We are uncertain about the compara-
30 days (CI 95% 0.13–2.63) per 1000 per 1000 Due to very serious risk of bias and tive effect of RYGB vs OAGB on
Difference: 59 fewer per 1000 very serious ­imprecision2 major morbidity
(CI 95% 136 fewer–174 more)
Minor ­morbidity3 Odds Ratio: 0.89 57 51 Very low We are uncertain about the compara-
30 days (CI 95% 0.09–9.09) per 1000 per 1000 Due to serious risk of bias, very tive effect of RYGB vs OAGB on
Difference: 6 fewer per 1000 serious publication bias and serious minor morbidity
(CI 95% 52 fewer–298 more) ­imprecision4
Improvement of d­ iabetes5 Odds Ratio: 1.74 942 966 Very low We are uncertain about the compara-
5 years (CI 95% 0.53–5.72) per 1000 per 1000 Due to serious risk of bias, seri- tive effect of RYGB vs OAGB on
Difference: 24 more per 1000 ous inconsistency and serious diabetes
(CI 95% 46 fewer–47 more) ­imprecision6
Improvement of sleep apnea Odds Ratio: 1.35 877 906 Very low We are uncertain about the compara-
5 years (CI 95% 0.14–12.5) per 1000 per 1000 Due to serious risk of bias, seri- tive effect of RYGB vs OAGB on
Difference: 29 more per 1000 ous inconsistency and serious sleep apnea
(CI 95% 377 fewer–112 more) ­imprecision7
Improvement of c­ holesterol8 Odds Ratio: 2.5 783 900 Very low We are uncertain about the compara-
5 years (CI 95% 0.24–25.0) per 1000 per 1000 Due to serious risk of bias and very tive effect of RYGB vs OAGB on
Difference: 117 more per 1000 serious ­imprecision9 cholesterol levels
(CI 95% 319 fewer–206 more)
Improvement of h­ ypertension10 Odds Ratio: 0.56 918 862 Very low We are uncertain about the compara-
5 years (CI 95% 0.2–1.54) per 1000 per 1000 Due to serious risk of bias and very tive effect of RYGB vs OAGB on
Difference: 56 fewer per 1000 serious ­imprecision11 hypertension
(CI 95% 227 fewer–27 more)
Improvement of osteoarthritis Odds Ratio: 0.28 872 656 Very low We are uncertain about the compara-
5 years (CI 95% 0.07–1.24) per 1000 per 1000 Due to serious risk of bias, seri- tive effect of RYGB vs OAGB on
Difference: 216 fewer per 1000 ous inconsistency and serious osteoarthritis
(CI 95% 549 fewer–22 more) ­imprecision12
Reoperation13 Odds Ratio: 1.01 56 57 Very low We are uncertain about the compara-
5 years (CI 95% 0.22–4.76) per 1000 per 1000 Due to serious risk of bias, seri- tive effect of RYGB vs OAGB on the
Difference: 1 more per 1000 ous inconsistency and serious risk of reoperation
(CI 95% 43 fewer–164 more) ­imprecision14
Excess weight loss Measured by: % 71.37 65.62 Low RYGB may have little or no differ-
5 years Scale:–High better Mean Mean Due to serious risk of bias and seri- ence in effect on excess weight loss
Difference: MD 4.75 lower ous ­inconsistency15 compared to OAGB
(CI 95% 12.43 lower–2.93 higher)
Surgical Endoscopy (2022) 36:1709–1725
 Table 3  (continued)

Outcome Study results and measurements Absolute effect estimates Certainty of the Evidence Plain language summary
Timeframe (Quality of evidence)
OAGB LRYGB
Quality of life Measured by: SD 0.89 0.79 Very low We are uncertain about the compara-
5 years Scale:–High better Mean Mean Due to very serious risk of bias and tive effect of RYGB vs OAGB on
Difference: SMD 0.91 lower very serious ­inconsistency16 quality of life
(CI 95% 0.53 lower–1.29 lower)
1
 30-day or in-hospital complications Clavien-Dindo ≥ 3
2
 Risk of Bias: very serious. Imprecision: very serious. Wide confidence intervals crossing panel-set minimal important difference
3
 30-day or in-hospital complications Clavien-Dindo ≥ 3
Surgical Endoscopy (2022) 36:1709–1725

4
 Risk of Bias: serious. Imprecision: serious. Wide confidence intervals crossing panel-set minimal important difference; Publication bias: very serious. Asymmetrical funnel plot
5
 Cessation or decrease of diabetes medication, or decrease in HbA1c levels
6
 Risk of Bias: serious. Inconsistency: serious. The magnitude of statistical heterogeneity was high and there is no direct estimate; Imprecision: serious. Wide confidence intervals crossing
panel-set minimal important difference
7
 Risk of Bias: serious. Inconsistency: serious. No direct estimates; Imprecision: serious. Wide confidence intervals crossing panel-set minimal important difference
8
 Decrease of cholesterol levels or cessation of medication
9
 Risk of Bias: serious. Imprecision: very serious. Wide confidence intervals crossing panel-set minimal important difference
10
 Decrease of blood pressure levels or cessation of medication
11
 Risk of Bias: serious. Imprecision: very serious. Wide confidence intervals crossing panel-set minimal important difference
12
 Risk of Bias: serious. Inconsistency: serious. No direct evidence and presence of incoherence; Imprecision: serious. Wide confidence intervals crossing panel-set minimal important differ-
ence
13
 Reoperation for any reason, including revisional operation
14
 Risk of Bias: serious. Inconsistency: serious. No direct evidence; Imprecision: serious. Wide confidence intervals crossing panel-set minimal important difference
15
 Risk of Bias: serious. Inconsistency: serious. The magnitude of statistical heterogeneity was high and there is no direct evidence
16
 Risk of Bias: very serious. Inconsistency: very serious. Evidence of very serious incoherence; Imprecision: no serious. Wide confidence intervals crossing panel-set minimal important
difference

13
1719

1720 Surgical Endoscopy (2022) 36:1709–1725

Table 4  Evidence to decision considerations

Benefits and harms Roux-en-Y gastric bypass and sleeve gastrectomy almost Substantial net benefits of the suggested alternative
consistently provided favorable risk/benefit ratio across
pairwise comparisons, and they occupied the highest
ranks in NMA. These findings are reflected in most panel
members' votes, ranking them higher than the rest of the
interventions. One anastomosis gastric bypass and single
anastomosis duodeno-ileal bypass with sleeve gastrectomy
were ranked higher than adjustable gastric banding and
gastric plication in several outcomes, however relevant
evidence was limited
Certainty of the evidence Overall certainty in effect estimates across outcomes was Low
low to very low, under consideration that evidence on
several critical outcomes was missing or it was of low or
very low certainty
Preferences and values Panel members unanimously agreed that substantial vari- Substantial variability is expected
ability in patient values and preferences is anticipated,
under consideration of the variety of features of obesity
and metabolic disease, and the different effect of different
interventions on different outcomes
Resources Most panel members suggested that cost or use of resources No important issues with the recommended alternative
(e.g. surgeon and surgical staff expertise, duration of
surgery, etc.) are variable among interventions. Roux-en-Y
gastric bypass and sleeve gastrectomy occupied the highest
rank as interventions with the least influence on the use of
resources
Equity Most panel members suggested substantial effect of different Important issues
interventions on equity (e.g. variable expertise in different
settings). Adjustable gastric banding and sleeve gastrec-
tomy occupied the highest ranks after panel voting in this
domain
Acceptability The vast majority of panel members agreed that there are No important issues with the recommended alternative
no issues with acceptability of different interventions to
key stakeholders. Sleeve gastrectomy, Roux-en-Y gastric
bypass and one anastomosis gastric bypass occupied the
highest ranks in panel votes
Feasibility Most panel members suggested issues with feasibility of Important issues
implementing a recommendation for either of the interven-
tions. Sleeve gastrectomy and adjustable gastric banding
occupied the highest ranks in panel votes

(Weak recommendation). one anastomosis gastric bypass and single anastomosis duo-
deno-ileal bypass. Evidence to decision considerations are
Rationale provided in Table 4.

The panel, under consideration of network meta-analysis

effect estimates and treatment rankings, considered that
Roux-en-Y gastric bypass and sleeve gastrectomy had the
best benefit/risk profile among interventions. One anasto-
mosis gastric bypass and single anastomosis duodeno-ileal
bypass with sleeve gastrectomy also demonstrated some
benefit, however relevant evidence was limited. Overall cer-
tainty of evidence was low to very low. Sleeve gastrectomy
and Roux-en-Y gastric bypass were ranked high in several,
but not all, evidence to decision domains, suggesting that
different bariatric interventions might be more appropriate in
different settings, hence a weak recommendation for Roux-
en-Y gastric bypass and sleeve gastrectomy, or alternatively
Discussion
The present guideline replaces relevant recommenda-
tions provided in the EAES Bariatric Guidelines 2020 [2].
Retracted work was excluded from qualitative and quantita-
tive assessments, and from the evidence to decision frame-
work [4].
Implications for policy makers
Summary findings and panels' input suggest that various
bariatric/metabolic interventions might be appropriate in

13
Surgical Endoscopy (2022) 36:1709–1725 1721
different settings and distinct patient populations. In health-
care facilities offering bariatric/metabolic surgery, infra-
structures (including surgeons' and operating room staff
expertise) should be in place for at least sleeve gastrectomy
and Roux-en-Y gastric bypass. Bariatric surgery training
curriculums are expected to include training in these inter-
ventions as a minimum.
Implications for healthcare professionals
Healthcare professionals are advised to consider back-
ground evidence on benefits and harms of each interven-
tion. Sleeve gastrectomy and Roux-en-Y gastric bypass
were prioritized by this multidisciplinary panel of Euro-
pean healthcare professionals with patient representation,
as the best interventions for most patients, followed by one
anastomosis gastric bypass and single anastomosis duo-
deno-ileal bypass with sleeve gastrectomy. Patient char-
acteristics and health condition, including obesity-related
morbidity, values and preferences, and surgical preference
and expertise may further inform the selection of the most
appropriate management course. Treatment options should
be discussed with patients for a tailored management of
their condition(s). Decision aids provided on MAGICapp
(https://​app.​magic​app.​org/#/​guide​line/​Lpv2kE)  may facili-
tate this process.
Implications for patients
Patients can be informed that the majority of evidence sur-
rounds sleeve gastrectomy and Roux-en-Y gastric bypass
with follow-up of up to 5 years. However, other management
options might be as, or even more, effective and the evi-
dence landscape may change in the future. They may want
to discuss these management options, under consideration
of risks/benefits of individual interventions, their condition
profile, and their own preferences. Patients may find decision
aids particularly helpful (https://​app.​magic​app.​org/#/​guide​
line/​Lpv2kE).
Implications for researchers
Further research on one anastomosis gastric bypass and sin-
gle anastomosis duodeno-ileal bypass with sleeve gastrec-
tomy is warranted. Longer duration follow-up of existing
RCTs is desired. Detailed reporting of baseline demo-
graphics with obesity-associated morbidity and subgroup
analyses of patients with type II diabetes mellitus, arterial
hypertension, sleep apnea, dyslipidemia, NAFLD/NASH
and osteoarthritis are essential. Reporting of important and
critical outcomes as presented herein is recommended. A
core outcome set for bariatric surgery may improve global
research reporting in the field.
Monitoring
Use of the guideline by EAES members will be monitored
through an online survey 2 years after publication. Feedback
from target users in the form of email communication, letters
to the editor, and comments in social media will be docu-
mented to be considered in future versions.
Validity period
A median of 4 RCTs fulfilling inclusion criteria of this sys-
tematic review were published per year. A scoping search
of clinicaltrials.gov using ‘obesity, morbid (condition or
disease)’ and ‘surgery (other terms)’ as entries and ‘not yet
recruiting’, ‘recruiting’, ‘enrolling by invitation’, ‘active, not
recruiting’ and ‘adults’ as limits, identified 164 records as of
November 16, 2021. Eleven RCTs would provisionally fulfill
the inclusion criteria of this guideline (see online appendix
[14]). Estimated study completion dates range between 2022
and 2036, with 2025 as the median year of estimated comple-
tion. By that year, 6 studies would have been completed. Esti-
mating the time between study completion and publication
at one year, these studies will have been published by 2026.
We do not anticipate any change in summary intervention
effects, rankings and evidence to decision parameters in the
short term. Under these considerations, the present guideline
is valid until December 2027.
Update
An update of this guideline is planned to take place in 2027,
if at least 5 RCTs with sufficient sample size will have been
published.
Conclusion
This guideline provides an evidence-informed recommenda-
tion and an evidence to decision framework, developed by
a multidisciplinary panel of stakeholders, using state-of-the
art statistical and guideline development methodology.
Supplementary Information  The online version contains supplemen-
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 00464-0​ 22-0​ 9008-0.
Funding  This project was sponsored and funded by the European
Association for Endoscopic Surgery and Other Interventional Tech-
niques. The funder had no influence on the development or the content
of this work.
13

1722
Declarations  surgery: update 2020 endorsed by IFSO-EC. EASO and ESPCOP
Disclosures  Francesco M. Carrano, Angelo Iossa, Nicola Di Lorenzo,
Gianfranco Silecchia, Katerina-Maria Kontouli, Dimitris Mavridis,
Isaias Alarçon, Daniel M. Felsenreich, Sergi Sanchez-Cordero, Angelo
Di Vincenzo, M. Carmen Balagué-Ponz, Rachel L. Batterham, Nicole
Bouvy, Catalin Copaescu, Dror Dicker, Martin Fried, Daniela Godor-
oja, David Goitein, Jason C.G. Halford, Marina Kalogridaki, Maurizio
De Luca, Salvador Morales-Conde Gerhard Prager,7 Andrea Pucci,
Ramon Vilallonga, Iris Zani, Per Olav Vandvik, Stavros A. Antoniou,
Ferdinando Agresta, Carmil Azran, Luca Busetto, Maura Buza, Berta
Gonzalo Prats, Jitka Herlesova, Giacomo Piatto, Suzanne Pruijssers,
Shlomi Rayman and Eugenia Romano have no conflict of interest or
financial ties to disclose. Detailed competing interests statements are
available in http://​osf.​io/​ktx2m.
Disclaimer  This clinical practice guideline has been developed under
the auspice of the European Association for Endoscopic Surgery
(EAES). It is intended to be used primarily by health professionals (e.g.
surgeons, anesthetists, physicians) and to assist in making informed
clinical decisions on diagnostic measures and therapeutic manage-
ment. It is also intended to inform individual practice of allied health
professionals (e.g. surgical nurses, dieticians, physical rehabilitation
therapists, psychologists); to inform strategic planning and resource
management by health care authorities (e.g. regional and national
authorities, health care institutions, hospital administration authorities);
and to inform patients wishing to obtain an overview of the condition
of interest and its management.
The use of recommendations contained herein must be informed by
supporting evidence accompanying each recommendation and by re-
search evidence that might not have been published by the time of writ-
ing the present document. Users must thus base their actions informed
by newly published evidence at any given point in time.
The information in the guideline should not be relied upon as being
complete or accurate, nor should it be considered as inclusive of all
proper treatments or methods of care or as a statement of the stand-
ard of care. With the rapid development of scientific knowledge, new
evidence may emerge between the time the guideline is developed and
when it is published or read. The guideline is not continually updated
and may not reflect the most recent evidence. The guideline addresses
only the topics specifically identified therein and is not applicable to
other interventions, diseases, or stages of diseases. This guideline does
not mandate any particular course of medical care. Further, the guide-
line is not intended to substitute the independent professional judgment
of the treating provider, as the guideline does not necessarily account
for individual variation among patients.
Even if evidence on a topic suggests a specific diagnostic and/or treat-
ment action, users and especially health professionals may need to
decide against the suggested or recommended action in view of cir-
cumstances related to patient values, preferences, co-morbidities and
disease characteristics; available human, monetary and material re-
sources; and healthcare infrastructures.
EAES provides this guideline on an “as is” basis, and makes no war-
ranty, express or implied, regarding the guideline.
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Publisher's Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
Surgical Endoscopy (2022) 36:1709–1725 1725

Authors and Affiliations

Francesco M. Carrano1 · Angelo Iossa2 · Nicola Di Lorenzo3 · Gianfranco Silecchia2 · Katerina‑Maria Kontouli4 ·

Dimitris Mavridis4,5 · Isaias Alarçon6 · Daniel M. Felsenreich7 · Sergi Sanchez‑Cordero8 · Angelo Di Vincenzo9 ·
M. Carmen Balagué‑Ponz10 · Rachel L. Batterham11,12 · Nicole Bouvy13 · Catalin Copaescu14 · Dror Dicker15 ·
Martin Fried16 · Daniela Godoroja17 · David Goitein18,19 · Jason C. G. Halford20 · Marina Kalogridaki21 ·
Maurizio De Luca22 · Salvador Morales‑Conde6 · Gerhard Prager7 · Andrea Pucci11,12 · Ramon Vilallonga23 ·
Iris Zani24 · Per Olav Vandvik25 · Stavros A. Antoniou26,27   · The EAES Bariatric Surgery Guidelines Group

14
* Stavros A. Antoniou Department of General Surgery, Ponderas Academic Hospital
guidelines@eaes.eu Regina Maria, Bucharest, Romania
15
1 Department of Internal Medicine D, Rabin Medical Center,
PhD Program in Applied Medical‑Surgical Sciences,
Hasharon Hospital, Sackler School of Medicine, Tel Aviv
University of Rome “Tor Vergata”, 00133 Rome, Italy
University, Tel Aviv, Israel
2
Department of Medical‑Surgical Sciences 16
Center for Treatment of Obesity and Metabolic Disorders,
and Biotechnologies, Faculty of Pharmacy and Medicine,
OB Klinika, Prague, Czech Republic
“La Sapienza” University of Rome-Polo Pontino, Bariatric
17
Centre of Excellence IFSO-EC, Rome, Italy Department of Anesthesiology, Ponderas Academic Hospital
3 Regina Maria, Bucharest, Romania
Department of Surgical Sciences, University of Rome “Tor
18
Vergata”, Viale Oxford 81, 00133 Rome, Italy Sackler School of Medicine, Tel Aviv University, Tel Aviv,
4 Israel
Department of Primary Education, School of Education,
19
University of Ioannina, Ioannina, Greece Department of Surgery C, Chaim Sheba Medical Center,
5 Ramat Gan, Israel
Faculté de Médecine, Université Paris Descartes, Paris,
20
France Department of Psychological Sciences, Institute
6 of Psychology, Health and Society, University of Liverpool,
Unit of Innovation in Minimally Invasive Surgery,
Liverpool, UK
Department of General and Digestive Surgery, University
21
Hospital “Virgen del Rocío”, 41010 Sevilla, Spain Emergency Department, General Hospital of Attica “KAT”,
7 Athens, Greece
Department of Surgery, Division of General Surgery, Vienna
22
Medical University, Vienna, Austria Division of General Surgery, Castelfranco and Montebelluna
8 Hospitals, Treviso, Italy
General Surgery Department, Consorci Sanitari de L’Anoia,
23
Barcelona, Spain Endocrine, Metabolic and Bariatric Unit, General Surgery
9 Department, Vall d’Hebron University Hospital, Center
Internal Medicine 3, Department of Medicine, DIMED;
of Excellence for the EAC-BC, Universitat Autònoma de
Center for the Study and the Integrated Treatment of Obesity,
Barcelona, Barcelona, Spain
University Hospital of Padua, Padua, Italy
24
10 EASO Patient Task Force, Middlesex, UK
Hospital Sant Pau, UAB, Barcelona, Spain
25
11 Department of Health Management and Health Economics,
Centre for Obesity Research, University College London,
University of Oslo, Oslo, Norway
London, UK
26
12 Surgical Department, Mediterranean Hospital of Cyprus,
Biomedical Research Centre, National Institute of Health
Limassol, Cyprus
Research, London, UK
27
13 Medical School, European University Cyprus, Nicosia,
Department of Surgery, Maastricht University Medical
Cyprus
Centre, Maastricht, The Netherlands

13