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 alternatives, 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.magicapp.org/#/guideline/Lpv2kE CONCLUSIONS: This rapid guideline provides evidence-informed, pertinent recommendations on the use of bariatric and metabolic surgery for the management of severe obesity and metabolic diseases. The guideline replaces relevant recommendations published in the EAES Bariatric Guidelines 2020.

Biomedical Research Centre National Institute of Health Research London UK

Center for Treatment of Obesity and Metabolic Disorders OB Klinika Prague Czech Republic

Centre for Obesity Research University College London London UK

Department of Anesthesiology Ponderas Academic Hospital Regina Maria Bucharest Romania

Department of General Surgery Ponderas Academic Hospital Regina Maria Bucharest Romania

Department of Health Management and Health Economics University of Oslo Oslo Norway

Department of Internal Medicine D Rabin Medical Center Hasharon Hospital Sackler School of Medicine Tel Aviv University Tel Aviv Israel

Department of Medical Surgical Sciences and Biotechnologies Faculty of Pharmacy and Medicine La Sapienza University of Rome Polo Pontino Bariatric Centre of Excellence IFSO EC Rome Italy

Department of Primary Education School of Education University of Ioannina Ioannina Greece

Department of Psychological Sciences Institute of Psychology Health and Society University of Liverpool Liverpool UK

Department of Surgery C Chaim Sheba Medical Center Ramat Gan Israel

Department of Surgery Division of General Surgery Vienna Medical University Vienna Austria

Department of Surgery Maastricht University Medical Centre Maastricht The Netherlands

Department of Surgical Sciences University of Rome Tor Vergata Viale Oxford 81 00133 Rome Italy

Division of General Surgery Castelfranco and Montebelluna Hospitals Treviso Italy

EASO Patient Task Force Middlesex UK

Emergency Department General Hospital of Attica KAT Athens Greece

Endocrine Metabolic and Bariatric Unit General Surgery Department Vall d'Hebron University Hospital Center of Excellence for the EAC BC Universitat Autònoma de Barcelona Barcelona Spain

Faculté de Médecine Université Paris Descartes Paris France

General Surgery Department Consorci Sanitari de L'Anoia Barcelona Spain

Hospital Sant Pau UAB Barcelona Spain

Internal Medicine 3 Department of Medicine DIMED; Center for the Study and the Integrated Treatment of Obesity University Hospital of Padua Padua Italy

Medical School European University Cyprus Nicosia Cyprus

PhD Program in Applied Medical Surgical Sciences University of Rome Tor Vergata 00133 Rome Italy

Sackler School of Medicine Tel Aviv University Tel Aviv Israel

Surgical Department Mediterranean Hospital of Cyprus Limassol Cyprus

Unit of Innovation in Minimally Invasive Surgery Department of General and Digestive Surgery University Hospital Virgen del Rocío 41010 Sevilla Spain

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Development of the International Federation for Surgery of Obesity and Metabolic Disorders-European Chapter (IFSO-EC) Grade-Based Guidelines on the Surgical Treatment of Obesity Using Multimodal Strategies: Design and Methodological Aspects