title: Evidence-based surgery: barriers, solutions, and the role of evidence synthesis.
abstract: BACKGROUND
  Surgery is a rapidly evolving field, making the rigorous testing of emerging innovations vital. However, most surgical research fails to employ randomized controlled trials (RCTs) and has particularly been based on low-quality study designs. Subsequently, the analysis of data through meta-analysis and evidence synthesis is particularly difficult.
  
  
  METHODS
  Through a systematic review of the literature, this article explores the barriers to achieving a strong evidence base in surgery and offers potential solutions to overcome the barriers.
  
  
  RESULTS
  Many barriers exist to evidence-based surgical research. They include enabling factors, such as funding, time, infrastructure, patient preference, ethical issues, and additionally barriers associated with specific attributes related to researchers, methodologies, or interventions. Novel evidence synthesis techniques in surgery are discussed, including graphics synthesis, treatment networks, and network meta-analyses that help overcome many of the limitations associated with existing techniques. They offer the opportunity to assess gaps and quantitatively present inconsistencies within the existing evidence of RCTs.
  
  
  CONCLUSIONS
  Poorly or inadequately performed RCTs and meta-analyses can give rise to incorrect results and thus fail to inform clinical practice or revise policy. The above barriers can be overcome by providing academic leadership and good organizational support to ensure that adequate personnel, resources, and funding are allocated to the researcher. Training in research methodology and data interpretation can ensure that trials are conducted correctly and evidence is adequately synthesized and disseminated. The ultimate goal of overcoming the barriers to evidence-based surgery includes the improved quality of patient care in addition to enhanced patient outcomes.
authors.affiliation: Department of Surgery and Cancer, Imperial College London, Queen Elizabeth The Queen Mother (QEQM) Building, St. Mary's Hospital Campus, London, W2 1NY, UK.
authors.forename: George
authors.initials: G
authors.lastname: Garas
authors.forename: Amel
authors.initials: A
authors.lastname: Ibrahim
authors.forename: Hutan
authors.initials: H
authors.lastname: Ashrafian
authors.forename: Kamran
authors.initials: K
authors.lastname: Ahmed
authors.forename: Vanash
authors.initials: V
authors.lastname: Patel
authors.forename: Koji
authors.initials: K
authors.lastname: Okabayashi
authors.forename: Petros
authors.initials: P
authors.lastname: Skapinakis
authors.forename: Ara
authors.initials: A
authors.lastname: Darzi
authors.forename: Thanos
authors.initials: T
authors.lastname: Athanasiou
mesh_terms: D004059:Diffusion of Innovation; D019317:Evidence-Based Medicine; D013502:General Surgery / Q000639:trends*; D006801:Humans; D015201:Meta-Analysis as Topic; D016032:Randomized Controlled Trials as Topic; D012107:Research Design; D012196:Review Literature as Topic