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Current status and future perspectives of collaboration in surgical research: A scoping review of the evidence

      Abstract

      Background

      Surgery is rapidly changing in terms of techniques, education, and methods of conducting research. To keep up with this pace, surgeons have recently focused on collaborative research projects. The aim of this review was to investigate practices for collaborations in surgical research.

      Methods

      A scoping review was conducted according to the guidelines proposed by Peters et al. Publications on patterns of collaboration in surgical research between January 2000 and December 2020, irrespective of the study design or language of publication, which were indexed in PubMed, the Cochrane Library, and Google Scholar, were included. A research librarian assisted in choosing the search terms and conducting the search. The very broad nature of the subject necessitated a pragmatic search strategy, with primary focus on reviews about collaboration. A new form of crowd science was used that explored collaborations using social media and online shared documents.

      Results

      The search identified 38 studies that covered different aspects of collaboration in surgical research. Global, specialist, trainee-/student-led, and patient-led collaboratives are growing in number and size. Implementation of information technologies in surgical collaboration is still limited. The review identified attempts to include researchers from low- and middle-income countries in these collaborations, but these were at the early stages.

      Conclusion

      There are many patterns of collaboration in surgical research. Involvement of low- and middle-income countries will lead to capacity building in these countries, fast recruitment for surgical trials, and more generalizability of trial results. Due to the complex nature of surgical research, implementation of information technologies might improve the quality of research.

      Introduction

      Surgery is rapidly changing both in terms of technology and techniques but also in terms of education and methods of conducting research. To keep pace, surgeons have recently focused on collaborative research projects. Surgical research addresses many vital clinical or service provision challenges to create surgical innovations, drive clinical advances, and optimize quality of care issues.
      • Souba W.W.
      • Wilmore D.W.
      Judging surgical research: how should we evaluate performance and measure value?.
      Despite the recent evidence-driven transformation in the provision of modern health care, investment in surgical research has not been commensurate. This might be attributed to a lack of time for surgeons to devote to research, a lack of departmental resources to support their projects, and insufficient training and mentorship for the development of academic surgery.
      • Rosengart T.K.
      • Rosengart T.K.
      • Mason M.C.
      • LeMaire S.A.
      • Brandt M.L.
      • Coselli J.S.
      • Curley S.A.
      • Mattox K.L.
      • Mills J.L.
      • Sugarbaker D.J.
      • Berger D.A.
      The seven attributes of the academic surgeon: Critical aspects of the archetype and contributions to the surgical community..
      In terms of global and public health, surgical diseases are under-represented in funding and program initiatives compared, for example, with infectious diseases.
      • Søreide K.
      • Alderson D.
      • Bergenfelz A.
      • et al.
      and the International Research Collaboration in Surgery (IRIS) ad hoc working group. Strategies to improve clinical research in surgery through international collaboration.
      Hu et al documented that surgery experienced a relative decrease of about $51.7 million in research funding over a 10-year period, and this mostly affected R-awards (ie, for research projects) and K-awards (ie, for mentored research).
      • Hu Y.
      • Edwards B.L.
      • Brooks K.D.
      • Newhook T.
      • Slingluff Jr., C.L.
      Recent trends in National Institutes of Health Funding for Surgery: 2003 to 2013.
      It is alarming that in addition to decreases in research funding, the volume of applications for funding by surgeons has also decreased. In fact, the success of applications for funding by surgeons has been conventionally lower than other physicians working in clinical or basic research disciplines.
      • Hu Y.
      • Edwards B.L.
      • Brooks K.D.
      • Newhook T.
      • Slingluff Jr., C.L.
      Recent trends in National Institutes of Health Funding for Surgery: 2003 to 2013.
      This is at a time when the need for translational research, outcomes investigation, epidemiologic studies, and clinical studies has increased. In a bid to address the complex nature of clinical research in surgery and its barriers, collaborations in surgical research have been introduced within and across global institutions and professional organizations. These alliances can add value to surgical research by narrowing proficiency gaps, building critical mass, and increasing efficiency, especially in this era of amplified focus on clinical productivity.
      A good example of such a collaboration is CovidSurg, an international collaboration which was established by the National Institute for Health Research Global Health Research Unit.
      NIHR Global Health Research Unit on Global Surgery
      CovidSurg – Globalsurg; 2020.
      This group seeks to analyze the effect of the pandemic on patients and services in surgery. Through its flagship cohort studies, the CovidSurg and CovidSurg-Cancer, it has published 5 practice-changing papers in high impact journals. The most recent work, GlobalSurg- CovidSurg Week, included a total of 142,815 patients across 1,677 centers in 122 countries, making it the largest documented global collaboration in surgery.
      NIHR Global Health Research Unit on Global Surgery
      CovidSurg – Globalsurg; 2020.
      The potential benefits of research collaboration suggest that investigation into mechanisms to improve and enable collaboration are needed.
      • Søreide K.
      • Alderson D.
      • Bergenfelz A.
      • et al.
      and the International Research Collaboration in Surgery (IRIS) ad hoc working group. Strategies to improve clinical research in surgery through international collaboration.
      While there has been tremendous growth in the research and collaborations in surgical research in the last decade, gaps exist in the critical review of information on this subject. This could ultimately limit availability of evidence to drive further practice-changing reforms and better collaborations.
      This scoping review therefore aimed to characterize the current domains of collaboration in surgical research, to identify best practices, and to highlight the efficacy of collaboration in surgical research.

      Methods

      This was a scoping review, because the body of literature exhibited a complex and heterogeneous nature not amenable to a more precise systematic review of the evidence.
      • Peters M.D.J.
      • Godfrey C.M.
      • Khalil H.
      • McInerney P.
      • Parker D.
      • Soares C.B.
      Guidance for conducting systematic scoping reviews.

       Objectives and inclusion criteria

      The primary objective of this scoping review was to map the key concepts that underpin collaboration in surgical research and collate literature about the effectiveness and experience of this collaboration. While the secondary objectives were to identify gaps in the research knowledge base, clarify key concepts, and report the types of evidence that address collaboration in surgical research.
      This review was constructed according to the guidelines suggested by Peters et al
      • Peters M.D.J.
      • Godfrey C.M.
      • Khalil H.
      • McInerney P.
      • Parker D.
      • Soares C.B.
      Guidance for conducting systematic scoping reviews.
      to determine what range of evidence (quantitative and/or qualitative) was available on the topic. There was therefore no data synthesis and no quality control
      • Munn Z.
      • Peters M.D.J.
      • Stern C.
      • Tufanaru C.
      • McArthur A.
      • Aromataris E.
      Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach.
      of the included studies. Owing to the very broad nature of the subject, the focus was to find reviews that described collaboration in research rather than dissect each type of collaboration. This scoping review, as such, may pave the way to systematic reviews in the future that investigate specific issues of collaboration in surgical research. Studies regarding patterns of collaboration and challenges in surgical research were included. The authors searched for studies describing best practices of developing and maintaining surgical collaborations in research.

       Search strategy

      Owing to the complex and broad nature of this topic, general search terms were kept broad to capture the most literature possible. The authors constructed a search thread based on their experience, inspired by the review by Søride et al
      • Søreide K.
      • Alderson D.
      • Bergenfelz A.
      • et al.
      and the International Research Collaboration in Surgery (IRIS) ad hoc working group. Strategies to improve clinical research in surgery through international collaboration.
      and assisted by a research librarian. The search thread below is pragmatic. The following search threads were used in PubMed, the Cochrane Library, and Google Scholar: (((((collabor∗[Title]) OR (cooper∗[Title])) OR (group[Title])) OR (consortium[Title])) OR (Consensus[Title])) AND (((surg∗[Title]) OR (oper∗[Title])) OR (intervention[Title])).
      These 3 databases were chosen, after consulting the research librarian, to provide the best possible overview. Adding more databases was discouraged by the librarian owing to the nature of the topics. The search was done by the first author (A.E.) and repeated by a specialist librarian at the Copenhagen University Library, Denmark, to ensure that all studies about the subject are included. The last day of the search was 3 March 2021. The studies were included irrespective of the language and surgical specialty. The authors chose publication years 2000 to 2020 to get an updated overview of the subject. The reference lists of the included studies were checked for any other relevant articles. The authors also used crowdsourcing to supplement their search by asking Twitter users for any studies about collaborative work in surgery. Data was collected in a similar manner to that used in the OpenSourceResearch collaboration (see the result section). The details of Twitter interactions are explained in the supplementary material for readers who are interested to know the tweets used, Twitter accounts of participants in the discussions, interactions, and global reach of this approach.
      Both authors contributed to the inclusion/exclusion of studies. The first author (A.E.) extracted data from the included studies, while the second author rechecked the extracted data. Any disagreement was resolved by discussion.

      Results

      The search identified 38 articles that covered different aspects of collaboration in surgical research. Figure 1 shows a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart of the selection process, and Table I shows the details of the included studies. The search results highlighted the following current domains of collaboration in surgical research, including collaborative authorship and crowd science.
      Figure thumbnail gr1
      Fig 1PRISMA flowchart showing the studies investigated and reasons for the exclusion. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
      Table IStudies included in this scoping review about collaboration in surgical research. The studies cover a broad spectrum of collaborative activities in research, mentorship, writing guidelines, and peer review
      NoAuthor (y)Title of the studyMethodStudy objectives
      Studies about collaboration in research
      1Sutzko, 2020
      • Sutzko D.C.
      • Mani K.
      • Behrendt C.A.
      • Wanhainen A.
      • Beck A.W.
      Big data in vascular surgery: registries, international collaboration and future directions.
      Big data in vascular surgery: registries, international collaboration, and future directionsNarrative reviewTo highlight the main vascular surgery registries and recap a few success stories of how the registries have been leveraged to benefit discovery, quality improvement, and ultimately patient care.
      2Caballero, 2019
      • Caballero C.
      • Burock S.
      • Carrion-Alvarez L.
      • et al.
      Building a collaboration to improve surgical research through EORTC/ESSO 1409-CLIMB study: a prospective liver metastasis database with an integrated quality assurance program.
      Building a collaboration to improve surgical research through EORTC/ESSO 1409-CLIMB studyNarrative reviewTo map out challenges and initiate a sustainable collaboration to advance cancer surgery research in Europe.
      3Agzarian, 2018
      • Agzarian J.
      • Shargall Y.
      Beyond borders—international database collaboration in thoracic surgery.
      Beyond borders—international database collaboration in thoracic surgeryNarrative reviewTo evaluate the role and key ingredients for successful international database collaborations.
      4Ruohoalho, 2018
      • Ruohoalho J.
      • Østvoll E.
      • Bratt M.
      • et al.
      Systematic review of tonsil surgery quality registers and introduction of the Nordic Tonsil Surgery Register Collaboration.
      Systematic review of tonsil surgery quality registers and introduction of the Nordic Tonsil Surgery Register CollaborationSystematic reviewTo investigate the existing tonsil surgery quality registers found in the literature and to provide a thorough presentation of the planned Nordic Tonsil Surgery Register Collaboration.
      5Rangel, 2017
      • Rangel S.J.
      Moving the needle toward high-quality pediatric surgical care: how can we achieve this goal through prioritization, measurement and more effective collaboration?.
      Moving the needle toward high-quality pediatric surgical care: How can we achieve this goal through prioritization, measurement, and more effective collaborationNarrative reviewTo investigate what quality measures should be captured and compared and to trace the evidence in support of collaborative networks.
      6Blencowe, 2017
      • Blencowe N.S.
      • Cook J.A.
      • Pinkney T.
      • Rogers C.
      • Reeves B.C.
      • Blazeby J.M.
      Delivering successful randomized controlled trials in surgery: methods to optimize collaboration and study design.
      Delivering successful randomized controlled trials in surgery: Methods to optimize

      collaboration and study design
      PerspectiveTo discuss several UK-based, surgical trial-related initiatives in detail and provide exemplar cases to illustrate how the methodological challenges have been tackled.
      7Hirschl, 2017
      • Hirschl R.B.
      • Minneci P.
      • Gadepalli S.
      • et al.
      and the MidWest Pediatric Surgery Consortium (MWPSC)
      Development of a multi-institutional clinical research consortium for pediatric surgery.
      Development of a multi-institutional clinical research consortium for pediatric surgeryPerspectiveTo present the process for creating, developing, and maintaining a consortium in pediatric surgery.
      8Jamjoom, 2016
      • Jamjoom A.A.B.
      • Phan P.N.H.
      • Hutchinson P.J.
      • Kolias A.G.
      Surgical trainee research collaboratives in the UK: An observational study of research activity and publication productivity.
      Surgical trainee research collaboratives in the UK: an observational study of research activity and publication productivityScoping reviewTo assess the current landscape of surgical trainee collaboratives in the United Kingdom, examine their activities, and quantify their scientific impact through the systematic analysis of their publication record.
      9Spence, 2016
      • Spence R.T.
      • Panieri E.
      • Rayne S.L.
      A multicentre evaluation of emergency abdominal surgery in South Africa: results from the Globalsurg-1 South Africa study.
      A multicentre evaluation of emergency abdominal surgery in South Africa: Results from the Globalsurg-1 South Africa studyProspectiveTo use data from hospitals in South Africa to compare risk-adjusted adverse outcomes among participating hospitals.
      10Morton, 2015
      • Morton M.J.
      • DeAugustinis M.L.
      • Velasquez C.A.
      • Singh S.
      • Kelen G.D.
      Developments in surge research priorities: a systematic review of the literature following the Academic Emergency Medicine Consensus Conference, 2007-2015.
      Developments in surge research priorities: A systematic review of the literature following the Academic Emergency Medicine Consensus Conference, 2007-2015Systematic reviewTo determine the progress toward the conference’s identified research priorities.
      11Waljee, 2014
      • Waljee J.F.
      • Birkmeyer N.J.O.
      Collaborative quality improvement in surgery.
      Collaborative quality improvement in surgeryNarrative reviewTo highlight the development and features of collaborative quality improvement programs.
      12Søreide, 2013
      • Søreide K.
      • Alderson D.
      • Bergenfelz A.
      • et al.
      and the International Research Collaboration in Surgery (IRIS) ad hoc working group. Strategies to improve clinical research in surgery through international collaboration.
      Strategies to improve clinical research in surgery through international collaborationNarrative reviewTo investigate international research collaboration in surgery.
      13Bhangu, 2013
      • Bhangu A.
      • Kolias A.G.
      • Pinkney T.
      • Hall N.J.
      • Fitzgerald J.E.
      Surgical research collaboratives in the UK.
      Surgical research collaboratives in the UKCorrespondenceTo present the structure and results of trainee-led regional networks in general surgery.

       Collaborative authorship

      Collaborative authorship in surgery has been discussed in a number of review articles.
      • Agzarian J.
      • Shargall Y.
      Beyond borders—international database collaboration in thoracic surgery.
      ,
      • Sutzko D.C.
      • Mani K.
      • Behrendt C.A.
      • Wanhainen A.
      • Beck A.W.
      Big data in vascular surgery: registries, international collaboration and future directions.
      ,
      • Gaardsted P.S.
      • Laursen H.S.
      • Poulsen S.H.
      • Krzyslak H.
      • El-Hussuna A.
      Increasing value and reducing waste in using and reusing datasets collected by surgical collaborating groups.
      ,
      • Jamjoom A.A.B.
      • Phan P.N.H.
      • Hutchinson P.J.
      • Kolias A.G.
      Surgical trainee research collaboratives in the UK: An observational study of research activity and publication productivity.
      Our scoping review provides only an overview of the different types of collaborations with some examples. However, detailed descriptions of collaboratives and their scientific production is outside the scope of this review.
      In the last 3 decades, there has been an increase in publications with large author collaborations where authors come together in so-called team science. A typical task for a study group is to generate data (set) based on a real-world population of patients.
      • Gaardsted P.S.
      • Laursen H.S.
      • Poulsen S.H.
      • Krzyslak H.
      • El-Hussuna A.
      Increasing value and reducing waste in using and reusing datasets collected by surgical collaborating groups.
      These collaboratives have developed policies for reporting authorship to comply with the International Committee of Medical Journal Editors authorship and General Medical Council guidelines.
      • Sutzko D.C.
      • Mani K.
      • Behrendt C.A.
      • Wanhainen A.
      • Beck A.W.
      Big data in vascular surgery: registries, international collaboration and future directions.
      In the last few decades, many collaboratives have emerged. Most of these collaboratives use a model whereby contributors collect data to be analyzed in 1 academic center, which has a well-established research infrastructure. In this model, the contributors are coauthors in all the papers produced based on data collected. This approach might allow for a larger number of patients to be recruited within a shorter period of time, prevent repetition, and permit greater generalizability of outcome in comparison to similar studies carried out in single centers.

       Trainee and student-led collaboratives

      Trainees are ideally placed to deliver this model of collaboration, because they follow a rotational pattern through several hospitals, are in regular contact with each other, are motivated, and require formalized evidence of research and audit as part of their training. The first regionally developed general surgical research collaborative was the West Midlands Research Collaborative.

      West Midlands Research Collaborative, https://wmrtc.org.uk/about. Accessed March 21, 2021.

      Many studies were published by this collaborative, for example “Reduction of surgical site infection using a novel intervention (ROSSINI): study protocol for a randomized controlled trial,” which recruited 760 patients from 21 centers to receive either a wound-edge protection device or continue with standard practice.
      • Pinkney T.D.
      • Calvert M.
      • Bartlett D.C.
      West Midlands Research Collaborative; ROSSINI Trial Investigators
      Impact of wound edge protection devices on surgical site infection after laparotomy: multicentre randomised controlled trial (ROSSINI Trial).
      Research collaboratives also enhance research skills and extend the scientific horizon of doctors-in-training.
      • Jamjoom A.A.B.
      • Phan P.N.H.
      • Hutchinson P.J.
      • Kolias A.G.
      Surgical trainee research collaboratives in the UK: An observational study of research activity and publication productivity.
      In the same vein, Student Audit and Research in Surgery (https://starsurg.org/) is a student-driven, national research network across the United Kingdom and Ireland, which was founded in 2013. It aimed to engage students in multicenter research studies early in their careers. Another example of a trainee-led research collaborative is the British Urology Researchers in Surgical Training (https://www.bursturology.com/), which was launched in 2015 and has more than 500 international collaborators. Low- and middle-income countries (LMICs) are not left out of surgical research collaboratives. For instance, under the auspices of the Research Collaborative Network of the National Association of Resident Doctors in Nigeria (https://nardrcn.com.ng/publications/), some trainees are currently working on multi-institution projects related to surgical themes.

       Specialized surgical collaboratives

      A recent systematic review
      • Gaardsted P.S.
      • Laursen H.S.
      • Poulsen S.H.
      • Krzyslak H.
      • El-Hussuna A.
      Increasing value and reducing waste in using and reusing datasets collected by surgical collaborating groups.
      identified 249 surgical collaboratives distributed across different surgical specialties. The publication activities of these surgical collaboratives increased with time to reach their peak in 2018. These specialized collaboratives may be spearheaded by a particular institution or a major society. For instance, the cohort studies committee in European Society of Coloproctology (ESCP) led 4 international snapshot audits in colorectal surgery (https://www.escp.eu.com/research/cohort-studies).
      Most of these collaboratives have built a database in which the data are prospectively added and maintained, such as the database maintained by Danish Colorectal Cancer Group. However, more than half of the surgical collaboratives have used their datasets only once.
      • Gaardsted P.S.
      • Laursen H.S.
      • Poulsen S.H.
      • Krzyslak H.
      • El-Hussuna A.
      Increasing value and reducing waste in using and reusing datasets collected by surgical collaborating groups.
      Many of these collaboratives used a multicenter international network of specialized surgeons: for instance, the ESCP, the Vascular Study Group of New England, SEARCH Database Study Group, and the Danish Colorectal Cancer Group.

       Global-oriented surgical collaboratives

      Recently, a promising type of surgical collaborative has emerged, with the main objective to improve collaboration with researchers from LMICs. These few collaboratives implemented different working models. The GlobalSurg collaborative for instance used the traditional model of conducting trials with the involvement of researchers from LMICs.
      NIHR Global Health Research Unit on Global Surgery
      CovidSurg – Globalsurg; 2020.
      GlobalSurg has also encouraged LMIC researchers to conduct trials related to clinical practice challenges in their settings. For example, the reduction of surgical site infection in LMICs.
      NIHR Global Health Research Unit on Global Surgery
      Pragmatic multicentre factorial randomized controlled trial testing measures to reduce surgical site infection in low- and middle-income countries: study protocol of the FALCON trial.
      Global-oriented collaboratives are sometimes formed in response to an emergency. The best example of this is CovidSurg Collaborative.
      NIHR Global Health Research Unit on Global Surgery
      CovidSurg – Globalsurg; 2020.
      During the first wave of the coronavirus disease 2019 (COVID-19) outbreak, the Birmingham trial unit established this collaborative to collect and analyze surgical data from several countries. This group has grown to include 1,677 centers in 122 countries globally. With the outbreak capturing much of the global attention, the COVIDSurg Collaborative has been able to publish in major medical journals. Other smaller, surgical-related collaboratives have since been founded during the present COVID-19 pandemic, including the PanSurg Collaborative (https://www.pansurg.org/) and CovidPaedCancer of the Global Childre’s NCDs (http://globalpaedsurg.com/global-childrens-ncd-launches-covidpaedscancer/).
      Surgical conditions in LMICs, a key cause of morbidity and mortality, account for almost one-third of the global burden of disease.
      • Philipo G.S.
      • Nagraj S.
      • Bokhary Z.M.
      • Lakhoo K.
      Lessons from developing, implementing and sustaining a participatory partnership for children’s surgical care in Tanzania.
      As global surgical capacity continues to expand, attention has focused on developing the academic surgical workforce in LMICs. Sub-Saharan Africa’s regional surgical societies continue to grow, with annual academic conferences increasing in attendance. Educational partnerships have begun to develop between sister surgical societies, which may result in expanding international research education.
      • Long K.L.
      • Galukande M.
      • Kyamanywa P.
      • Tarpley M.J.
      • Dodgion C.
      and the Global Affairs Committee of the Association for Academic Surgery
      Developing research potential and building partnerships: a report of the fundamentals of surgical research course at the college of surgeons of East, Central, and Southern Africa.
      Examples of such collaboration aiming to reduce surgical site infections in LMICs is FALCON trial.
      NIHR Global Health Research Unit on Global Surgery
      Pragmatic multicentre factorial randomized controlled trial testing measures to reduce surgical site infection in low- and middle-income countries: study protocol of the FALCON trial.
      Another example is the collaborative to improve trauma care in LMICs.
      • Rosenberg A.
      • Uwitonze J.M.
      • Dworkin M.
      • et al.
      Fostering trauma and emergency research capacity in Rwanda through collaboration: research capacity building in Rwanda.

       Patient-led collaboratives

      The PAPooSE Study is an audit of existing inflammatory bowel disease (IBD) obstetric services in the United Kingdom. The study aimed to review the existing medical literature about stoma and pregnancy to create a long list of potential concerns, survey existing IBD obstetric practices, and use an online patient questionnaire to assess what patients experience during pregnancy and what information they would want to be provided by their health care teams. Identifying the clinical sequalae of pregnant patients with a stoma can help establish best practice in advising and managing future patients, in addition to highlighting areas for future research and multidisciplinary intervention.
      Surgical collaboratives have achieved many of their objectives; however, these collaboratives have many threatening challenges that must be addressed to take collaboration in surgical research a step further. The achievements and the challenges facing surgical collaboratives are shown in Table II.
      Table IIThe achievements of surgical collaboratives and the challenges threatening this type of collaboration in research
      Achievements of collaboratives
      1These collaboratives have engaged many physicians and surgeons thus giving the participants the opportunity to experience medical research.
      2These collaboratives strengthen skills and experience on large-scale research coordination at the central site. The coordinating center gains intangible assets like data, data management skills, and the know-how of the organization of research. They also gain funding, as well as national and international influence.
      3Some of the collaboratives, like the GlobalSurg collaborative, has tackled issues in LMICs using the skills of researchers from high-income countries.
      4New designs have emerged from these collaboratives. For instance, the Eagle study, conducted by the ESCP cohort studies committee, used clustered, randomized controlled trial design; while the #OpenSourceResearch collaboration researched patient-reported outcome measures in colorectal surgery using the Twitter platform to involve patients in the discussions.
      • El-Hussuna A.
      • Rubio-Perez I.
      • Millan M.
      • et al.
      OpenSourceResearch collaboration
      Patient-reported outcome measures in colorectal surgery: Construction of core measures using open source research method [e-pub ahead of print].
      5Hospitals all over the world, including those in conflict zones, contributed patients to collaborative studies. This shows that global collaboration is an untapped potential source of medical research.
      6International research collaborations in surgery between developed and developing countries could encourage capacity building and quality improvement and mutually enhance care for patients with surgical disorders.
      • Søreide K.
      • Alderson D.
      • Bergenfelz A.
      • et al.
      and the International Research Collaboration in Surgery (IRIS) ad hoc working group. Strategies to improve clinical research in surgery through international collaboration.
      Collaboratives have led to the enhancement of clinical and research infrastructure in developing countries like Nigeria and Senegal.
      7Collaboratives have made huge strides in establishing an infrastructure to address surgical multicenter randomized trials, which are essential to establish evidence-based practice and inform health policy, but their design and conduct has historically been hampered by the lack of a collaborative research culture among surgeons and by the challenges posed by the surgical setting/context.
      • Blencowe N.S.
      • Cook J.A.
      • Pinkney T.
      • Rogers C.
      • Reeves B.C.
      • Blazeby J.M.
      Delivering successful randomized controlled trials in surgery: methods to optimize collaboration and study design.
      Challenges that threaten collaborative research in surgery
      1Coordinating centers, where most of the infrastructure lies, determine the terms of the collaboration, allowing little or no influence from collaborating partners.
      2Limited or no reuse of the collected data.
      • Gaardsted P.S.
      • Laursen H.S.
      • Poulsen S.H.
      • Krzyslak H.
      • El-Hussuna A.
      Increasing value and reducing waste in using and reusing datasets collected by surgical collaborating groups.
      3Information technologies and web-based collaboration is still in its infancy. Collaboration using innovative techniques for collection and analysis of electronic information about patients, linked to prospective clinical registries and rapid learning systems, is an untapped source of research.
      • Søreide K.
      • Alderson D.
      • Bergenfelz A.
      • et al.
      and the International Research Collaboration in Surgery (IRIS) ad hoc working group. Strategies to improve clinical research in surgery through international collaboration.
      These learning systems allow for responses to the information gathered, such as correction of clinical practice for optimum care, and ensure reduction of errors.
      4Very limited or nonexistent data sharing between collaboratives. An attempt to share data and establish a collaboration with the medical industry is underway by the ESCP research committee [Internal communication].
      5Limited collaboration between these collaboratives with the exception of endorsements and courtesy acknowledgements.
      6There is no overall strategic coordination among the collaboratives and the organizations supporting them. International cooperation and networking among organizations for health technology assessment for instance could avoid duplication of effort and maximize outputs.
      • Søreide K.
      • Alderson D.
      • Bergenfelz A.
      • et al.
      and the International Research Collaboration in Surgery (IRIS) ad hoc working group. Strategies to improve clinical research in surgery through international collaboration.
      7There are many barriers to international collaboration that must be overcome by the adoption of global strategies for regulation, health insurance, ethical approval, and indemnity coverage for doctors.
      • Søreide K.
      • Alderson D.
      • Bergenfelz A.
      • et al.
      and the International Research Collaboration in Surgery (IRIS) ad hoc working group. Strategies to improve clinical research in surgery through international collaboration.
      ESCP, the European Society of Coloproctology.

       Crowd science

      A growing amount of scientific research is done in an open collaborative fashion, in projects sometimes referred to as “crowd science,” “citizen science,” or “networked science.”
      • Franzoni C.
      • Sauermann H.
      Crowd science: the organization of scientific research in open collaborative projects.
      This type of research is characterized by 2 important features: participation in the project is open to a wide base of potential contributors and intermediate inputs, such as data or problem solving algorithms, are made openly available.
      • Franzoni C.
      • Sauermann H.
      Crowd science: the organization of scientific research in open collaborative projects.
      Many successful crowd science projects are explained by Franzoni et al.
      • Franzoni C.
      • Sauermann H.
      Crowd science: the organization of scientific research in open collaborative projects.
      Another type of crowd science is collaborative writing. Applications such as wikis and Google Docs might have positive effects on health care, such as improved collaboration, behavioral change, learning, knowledge management, and adaptation of knowledge to local context. However, these benefits have never been assessed systematically.
      • Archambault P.M.
      • van de Belt T.H.
      • Kuziemsky C.
      • et al.
      Collaborative writing applications in healthcare: Effects on professional practice and healthcare outcomes.
      Moreover, several questions regarding safety, reliability, and legal aspects exist.
      • Archambault P.M.
      • van de Belt T.H.
      • Kuziemsky C.
      • et al.
      Collaborative writing applications in healthcare: Effects on professional practice and healthcare outcomes.
      #OpenSourceResearch collaboration is a crowd science
      • Yalcinkaya A.
      • El-Hussuna A.
      and the OpenSourceResearch Collaborating Group
      #OpenSourceResearch: a novel medical research technique/style in terms of accessibility and way of work.
      ,
      • El-Hussuna A.
      • Emile S.H.
      • Wexner S.D.
      Comment on: Novel approaches to surgical trials and the assessment of new surgical technologies.
      initiative that is growing in size and global reach. The #OpenSourceResearch collaboration has been active in surgical research, and it is presented in more details below.
      Information technologies have revolutionized the world of commerce, finance, and communication. Yet, their impact on scientific research is still limited. Emerging technologies, including telemedicine and web-based modules, eased collaboration in surgical research.
      • Søreide K.
      • Alderson D.
      • Bergenfelz A.
      • et al.
      and the International Research Collaboration in Surgery (IRIS) ad hoc working group. Strategies to improve clinical research in surgery through international collaboration.
      The widespread use of social media enabled networking and collaboration among investigators.
      • Søreide K.
      Numbers needed to tweet: social media and impact on surgery.
      In 2018, Professor Julio Mayol from Madrid University, Spain, constructed a network to connect surgeons on Twitter under the name “#SoMe4Surgery.”
      • Ioannidis A.
      • Blanco-Colino R.
      • Chand M.
      • et al.
      How to make an impact in surgical research: a consensus summary from the #SoMe4Surgery community.
      Shortly after its start, this network expanded rapidly
      • Ioannidis A.
      • Blanco-Colino R.
      • Chand M.
      • et al.
      How to make an impact in surgical research: a consensus summary from the #SoMe4Surgery community.
      and provided a collaboration opportunity to researchers.
      Inspired by open-source coding, which gave birth to Linux, Android, and WordPress, these researchers started the #OpenSourceResearch collaboration.

      OpenSourceResearch Collaboration, 2020. https://www.opensourceresearchcollaboration.net/. Accessed March 21, 2021.

      The idea behind this initiative was formulated as follows: if programmers can collaborate to produce codes and contribute online to a large project, then researchers might also be able to collaborate online to produce research. A group of researchers from different parts of the world explored the possibility of conducting scientific research using on-line tools, like shared Google Docs and the Twitter platform.
      • El-Hussuna A.
      • Myrelid P.
      • Holubar S.D.
      • et al.
      Biological treatment and the potential risk of adverse postoperative outcome in patients with inflammatory bowel disease: an open-source expert panel review of the current literature and future perspectives.
      The experiment was launched in September 2018 with a review article about the effect of biological agents on postoperative outcome in patients with IBD.
      • El-Hussuna A.
      • Myrelid P.
      • Holubar S.D.
      • et al.
      Biological treatment and the potential risk of adverse postoperative outcome in patients with inflammatory bowel disease: an open-source expert panel review of the current literature and future perspectives.
      The choice of subject was based on the expertise of the research group. A Google document was created, which was shared across social media. Comments and edits were verified by the authors to ensure accuracy and consistency. The manuscript was presented on Twitter in sequential posts. Each post contained 1 to 2 paragraphs of the manuscript, modified to fit the limited space in Twitter. This collaboration was unique in the way it was written and edited (Fig 2). The final draft was sent by email to all contributors for feedback before submission. Contributors became coauthors in the paper based on this collaboration.
      Figure thumbnail gr2
      Fig 2Wisdom of crowds is the idea that large groups of people are collectively smart when it comes to problem solving, decision-making, innovating, and predicting. The power of this concept is based on intellectual diversity of the crowd. The diagram shows how the #OpenSourceResearch collaboration used the wisdom of the crowd to produce many scientific papers.
      Because the above-mentioned paper was written as a social media-based collaboration, it was important to capture social media activity, as potential source material for the paper, to assess the response to the idea of an open-source research paper, and to document the main influencers of these discussions.
      • El-Hussuna A.
      • Myrelid P.
      • Holubar S.D.
      • et al.
      Biological treatment and the potential risk of adverse postoperative outcome in patients with inflammatory bowel disease: an open-source expert panel review of the current literature and future perspectives.
      Data were collected through 2 tools—“Followthehashtag” for geographical mapping and gender split of tweeters and “NodeXL” to document the networking interactions between tweeters and describe the interactions between these tweeters (replies, retweets, and mentions of other tweeters). Both tools can be used to quantify the number of tweeters, retweeters, and tweets. Both tools also provide information about individual tweets (History can be found on http://analytics.followthehashtag.com/#!/?id=dashboard).
      The first paper produced by this collaboration was published in Crohn Colitis 360
      • El-Hussuna A.
      • Myrelid P.
      • Holubar S.D.
      • et al.
      Biological treatment and the potential risk of adverse postoperative outcome in patients with inflammatory bowel disease: an open-source expert panel review of the current literature and future perspectives.
      and sparked a good scientific debate about the subject on Twitter. The reader is referred to supplementary material about the Twitter accounts, tweets, retweets, and activities related to this paper. The success of this experiment led to a new, more ambitious experiment.
      In January 2019, the researchers joined forces with patients and patient advocates to experiment with the possibility of conducting an online study using Twitter as a platform for discussions. Patient-reported outcome measures (PROMs) in colorectal surgery are standard measures in the assessment of postoperative outcomes based on patients’ perspectives. PROMs are important, as there can be divergence in the patients’ perspectives from those of the treating clinicians; therefore, the subject was chosen after a Twitter poll conducted in January 2019 (Twitter account of @AlaaEl_Hussuna).
      After a review of the existing literature about the most-used PROMs in colorectal cancer and IBD, the study coordinators presented and discussed the 5 most used PROMs in colorectal surgery on Twitter using text and images/slides. Inputs and comments from a wide spectrum of participants, including researchers, surgeons, physicians, nurses, patients, and patient organizations were collected and documented in a shared Google document, which was made accessible online. Although the outbreak of COVID-19 disrupted this project, it achieved many of its goals, among them raising awareness about PROMs and showing that a large number of PROMS sets are not used in daily clinical practice. It proved also that patients active on social media could have a voice in these discussions. The paper was recently published in a surgical journal.
      • El-Hussuna A.
      • Rubio-Perez I.
      • Millan M.
      • et al.
      OpenSourceResearch collaboration
      Patient-reported outcome measures in colorectal surgery: Construction of core measures using open source research method [e-pub ahead of print].
      The interested reader is referred to supplementary files about Twitter interactions and the log file showing these discussions.
      Both papers showed that the lack of coordination in scientific research led to a waste of resources and a delay in progress in generating knowledge.
      • El-Hussuna A.
      • Myrelid P.
      • Holubar S.D.
      • et al.
      Biological treatment and the potential risk of adverse postoperative outcome in patients with inflammatory bowel disease: an open-source expert panel review of the current literature and future perspectives.
      Thus, using Twitter to debate and share knowledge might improve the outcome of surgical research. The 2 papers also showed the need for a road map to describe collaboration in surgical research with achievable, measurable, and scalable milestones.
      • El-Hussuna A.
      • Myrelid P.
      • Holubar S.D.
      • et al.
      Biological treatment and the potential risk of adverse postoperative outcome in patients with inflammatory bowel disease: an open-source expert panel review of the current literature and future perspectives.
      Thus, a scoping review about the issue was deemed necessary.
      Upon conducting this scoping review, the authors asked for feedback about the types of collaboration in surgical research. The existence of patient-led collaboration for instance was identified through this Twitter thread. Many of the participants in the first 2 projects joined discussions about collaboration in surgical research (Twitter accounts are presented in supplementary files). The Twitter activities in this review were limited because, contrary to the other 2 #OpenSourceResearch projects, no previous review existed about collaboration in surgical research.
      Projects such as the above-mentioned study might pave the way for a new method of research, where patients can be widely involved in surgical projects.
      • El-Hussuna A.
      • Rubio-Perez I.
      • Millan M.
      • et al.
      OpenSourceResearch collaboration
      Patient-reported outcome measures in colorectal surgery: Construction of core measures using open source research method [e-pub ahead of print].
      Figure 2 shows the concept of OpenSourceResearch collaboration, and how social media was used in producing research.
      However, crowd science is threatened by many organizational and motivational challenges, as discussed in detail in the paper by Franzoni et al.
      • Franzoni C.
      • Sauermann H.
      Crowd science: the organization of scientific research in open collaborative projects.
      The most important of these challenges are the following.

       Matching projects and people

      Organizational mechanisms are needed to allow for the efficient matching of projects and potential contributors with respect to both skills and interests. One potential approach makes it easier for individuals to find projects by aggregating and disseminating information on ongoing or planned projects. An efficient alternative mechanism may be crowd-science platforms that host multiple projects and allow them to use a shared pool of potential contributors, as well as a shared technical infrastructure. This is especially true if projects are similar with respect to the field of science, types of tasks, or skill requirements; individuals who contributed to one project are also likely to be suitable contributors to another project on the same platform (example #SoMe4Surgery).

       Division of labor and integration of contributions

      Projects differ with respect to the complexity and structure of the task that is outsourced to the crowd. The more complex and ill-structured the task, the more contributors must interact and build on each other's contributions, limiting the number of people who can work on a given project at the same time.

       Project leadership

      Crowd-science projects require a significant amount of project leadership. Depending on the nature of the problem, leaders are fundamental in framing the scientific experiment, modularizing the task, securing access to financial and technical resources, or making decisions regarding how to proceed at critical junctures of a project and to find the overall problem solution.

       Sustaining contributor involvement

      In many crowd-science projects (#OpenSourceResearch collaboration included), the majority of participants make only small and infrequent contributions, often stopping shortly after joining. Thus, mechanisms to increase the involvement of less frequent contributors may dramatically increase the amount of work a project can accomplish.

       Supporting a broader set of motivations

      Crowd-science projects can successfully satisfy certain motives such as intellectual challenge, interest in a particular area of science, or the desire to contribute to scientific research. Yet, projects may also need to find better ways to attract professional scientists or firms, because these potential contributors often possess unique capabilities as project organizers, specific kinds of domain specific skills, or downstream capabilities that are necessary to translate scientific results into useful products or services.

       Reconciling conflicting motivations

      If crowd-science projects seek to attract participants with different types of motives, conflicts may arise. However, the open-source software experience suggests that different motivations can coexist within a project and that, with potential incentives, conflicts can be mitigated using contractual mechanisms.

      Discussion

      This scoping review investigated collaboration in surgical research and detailed the published evidence for different types of collaboration, from the well-known patterns like corporate authorship to the newer form of collaboration such as crowd science. The review identified issues regarding LMICs involvement in surgical research, implementing information technologies, and challenges that threaten collaboration.
      LMICs experience similar surgical diseases as high-income countries (eg, cancer, cardiovascular disease, and the surgical sequelae of metabolic syndrome), and as such, collaboration is of mutual interest.
      • Søreide K.
      • Alderson D.
      • Bergenfelz A.
      • et al.
      and the International Research Collaboration in Surgery (IRIS) ad hoc working group. Strategies to improve clinical research in surgery through international collaboration.
      Collaboration serves 2 important goals: first, building capacity in LMICs and, second, improving generalizability of the results and rapid recruitment into large trials. Improvements in both areas might speed up the adoption and breadth of specific practices.
      • Søreide K.
      • Alderson D.
      • Bergenfelz A.
      • et al.
      and the International Research Collaboration in Surgery (IRIS) ad hoc working group. Strategies to improve clinical research in surgery through international collaboration.
      Collaboratives have led to the enhancement of clinical and research infrastructure in developing countries like Nigeria and Senegal. Intangible assets, such as data management skills, and tangible resources, such as surgical accessories and information technology facilities, could be gained by the participating institutions. It has further improved the international influence and networks of the involved centers. As hospitals all over the world, including those in conflict zones, contribute patients to collaborative studies, global surgery collaboration represents an untapped potential source of medical research that may lead to faster results and wider applicability than single-country trials.
      • Søreide K.
      • Alderson D.
      • Bergenfelz A.
      • et al.
      and the International Research Collaboration in Surgery (IRIS) ad hoc working group. Strategies to improve clinical research in surgery through international collaboration.
      As the landscape of health care data is changing rapidly, ensuring that LMICs have the resources to keep up-to-date with technological advances will ensure future global health equity.
      • Schwalbe N.
      • Schwalbe N.
      • Wahl B.
      Artificial intelligence and the future of global health. 2020 May 16;395(10236): PMID: 32416782; PMCID: PMC7255280..
      Surgeons educated in research methods and aided by research networks and trial centers are needed to foster international collaborations.
      • Søreide K.
      • Alderson D.
      • Bergenfelz A.
      • et al.
      and the International Research Collaboration in Surgery (IRIS) ad hoc working group. Strategies to improve clinical research in surgery through international collaboration.
      Collaboratives have given surgeons in LMICs the opportunity to experience well-designed and practice-changing medical research. The skills and experience for large-scale research coordination is thus improved, not just at the central site but also at hubs and spokes. New study designs have also emerged from these collaboratives. For instance, the Eagle study, conducted by the ESCP cohort studies committee, used clustered, randomized controlled trial design, while #OpenSourceResearch collaboration researched PROMs in colorectal surgery and implemented the principle of crowd science on the Twitter platform.
      • El-Hussuna A.
      • Rubio-Perez I.
      • Millan M.
      • et al.
      OpenSourceResearch collaboration
      Patient-reported outcome measures in colorectal surgery: Construction of core measures using open source research method [e-pub ahead of print].
      Despite this, surgical research can be difficult even in centers with well-developed infrastructure. Many of the challenges in surgical research relate to the fact that surgical procedures are complex health care interventions that are inter- and intra-operator dependent, meaning that “unlike 20-milligram tablets, no 2 surgical procedures are the same.
      • Blencowe N.S.
      • Cook J.A.
      • Pinkney T.
      • Rogers C.
      • Reeves B.C.
      • Blazeby J.M.
      Delivering successful randomized controlled trials in surgery: methods to optimize collaboration and study design.
      ” Challenges for evaluation arise from surgeons’ personal preferences, as well as their skill level and ability to learn new techniques. Surgical procedures also involve other team members (ie, anesthetists, surgical assistants, and nurses) and associated pre-, peri-, and post-operative interventions, all of which may influence the overall outcome of an operation.
      • Blencowe N.S.
      • Cook J.A.
      • Pinkney T.
      • Rogers C.
      • Reeves B.C.
      • Blazeby J.M.
      Delivering successful randomized controlled trials in surgery: methods to optimize collaboration and study design.
      The complex nature of surgical procedures necessitates a complex and innovative design of scientific studies, which might be enhanced by using operation research science and advances in information technologies. Operation research is the application of modern methods of mathematical science to complex problems, involving the management of large systems of people, machines, materials, and money in industry, business, government, and defense. Effective data deidentification, sharing, and integration tremendously improves clinical research. By choosing to focus on information technologies to support clinical research, we can pave the way to innovation, stay abreast of technologies, and avoid a situation where clinicians are left behind.
      In the same vein, professional surgical organizations, funding agencies, and government agencies supervising surgical research should support and optimize the collaboration. Funding agencies can attribute higher priorities to collaborative research compared with research originating from a single academic center. Professional organizations can promote new ideas and stimulate debates that challenge old dogmas. Governmental agencies can facilitate access to data and support researchers in the academic centers who are under increasing pressure to focus on clinical production, sacrificing research time.
      This scoping review has some limitations. The study used broad search terms owing to the nature of the subject. More specific studies, indexed using other terms, could have been missed. The quality of evidence was not assessed owing to the nature of the subject and heterogeneity of the included studies, which were heterogeneous both in design and conduct. However, the study provided an overview about collaboration in surgical research and directed the interested readers to more specific studies about these forms of collaboration.
      In conclusion, international collaboration in surgical research is crucial and may improve the number of trials done, the quality of data obtained from these trials, and the generalizability of the results achieved. The potential for major public health gains through international collaboration in surgical research is high and may be particularly useful in LMICs. The unrealized potential of international research collaboration should be exploited by surgeons to arrive at robust answers for questions about optimum treatment of patients with surgical disorders.

      Funding/Support

      None.

      Conflicts of interest/Disclosures

      None.

      Ethical approval

      Not applicable for this type of study.

      Supplementary Materials

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