Symptomatic hypoglycemia was found in 4 patients all managed with dietary changes and 1 with acarbose. Four patients had a preoperatively diagnosis together of bipolar disorder and they all underwent a gastric bypass. Weight loss was excellent in 3 and average in 1 but management of the psychiatric disorder was very difficult in all with two even contemplating suicide. All 9 patients having gastric banding lost >50% excess body weight. However, weight regain occurred in all with an average excess body weight loss of 33%. Three patients developed gastric band erosions requiring removal and conversion to sleeve gastrectomy. One patient developed an early slippage and had the band removed by another surgeon. Two of the band erosion patients developed port site infections requiring removal of the subcutaneous ports prior to band removal.

All bands were placed very early in the series and this procedure has since been abandoned (Table 2). Fifteen patients underwent sleeve gastrectomy with average followup of 8 months. Ages ranged from 6�C68 years. Average weight loss is 55.4% excess weight. One patient developed a gastroparesis which required endoscopic placement of a nasojejunal tube for feeding (Table 2). This was removed after 8 days when the patient was able to swallow again. This patient had lost 27.7kg in a 6-month period. Two patients had sleeves as the first part of a 2-stage operation (due to super morbid obesity) one of whom required to be converted to a gastric bypass. 4. Discussion The major finding of the present study is that laparoscopic bariatric surgery can be performed in a low-volume center in a third world setting with low complication rates.

The American Society for Bariatric Surgery (ASBS) has proposed categorization of certain bariatric surgical practices into ��Centers of Excellence�� for bariatric surgery. Criteria for becoming a center of excellence include a threshold volume of bariatric surgical cases per year, operative outcomes, and the presence of a multidisciplinary commitment to management of the morbidly obese (Table 3) [11]. Table 3 Proposed criteria for becoming a center of excellence according to the American Society for Bariatric Surgery. The relationship between volume and outcome has been established in several complex abdominal operations [12, 13]. However successful procedure outcomes can be achieved by surgeons in low volume centers [14]. The concept of centralization of surgery into specialized and superspecialized centers may not apply to less populous nations [15]. Accreditation GSK-3 of Centers of Excellence in bariatric surgery requires a hospital volume of more than 125 procedures/year. Controversy exists about the perioperative safety of bariatric surgery and the relationship between volume and outcomes.