Colorectal travelling fellowships: Exploring current perspective and future direction

Travelling Surgical fellowships (TSF) have a longstanding tradition in promoting out-of-programme surgical training, fostering collegiality and collaboration among surgeons. In this retrospective review we explore its historical context and examine existing practices and likely future trends. More specifically, we focus on colorectal travelling fellowships (CTF) and provide additional quantitative and qualitative analyses, highlighting the most valued theme-based surgical experiences and examine their merits and impacts. The TSF time-series analysis was based on a total of 350 awarded fellowships from 2000 to 2019. CTF analysis was based on 98 fellowships. The accelerated utilization of internet-based virtual interaction during the COVID-19 Pandemic has offered an opportunity to examine its possible intermediate and long-term disruptive effects.


Background
Travel has long been considered a tradition associated with surgical development, learning, and friendship. Its influence can be traced as far back as the early nineteenth century when it helped to uproot established surgical traditions whilst facilitating the democratizations within surgical practice [3,4]. Following World War I (WWI), it provided an impetus for the dissemination of operative knowledge, the use of new technologies, the convergence of surgical practices, and the establishment of professional surgical organizations [1,2].
Facilitated by improved means of transportation and enabled by periods of world peace and prosperity, the concept of Surgical Travelling Fellowships (TSF) has evolved in response to the rapid advances in surgical practice. Early accounts by eminent surgeons such as William Halsted (1904) and Edward Churchill, (1926) both from the United States indicate how travel to multiple academic surgical institutions in Europe had a lasting impact on their patient care and on the subsequent foundation of structured graduate training programs for surgeons in the United States [5]. Other examples include the Travelling Surgical Society of Great Britain and Ireland, established in 1924, and the Moynihan Travelling Fellowship, founded in 1937, both of which recognised the need to promote travel and TSFs to showcase achievements in surgery and to improve surgeon-to-surgeon connectivity, nationally and internationally [6,7].
In colorectal surgery, TSFs (CTF) have benefited more recently from the international partnerships with colleges of surgery, surgical associations, as well as colorectal and philanthropic societies. The strategic aim has been to encourage out-of-programme surgical training, to offer learning and training opportunities to surgeons from middle and lowincome countries, and to foster collegiality and collaboration among the international surgical community [10,11,14]. The current pathway for CTS consists of a selection process for candidate, leading to the award of a sponsorship, followed by travel and host-based engagements. The financial support, duration, and program structure vary considerably and are largely determined by the specific mission for each fellowship (Table 1).
Pre-Covid figures on the number of CTF, published by the European Society of Coloproctology (ESCP), show a sustained increase in supply and demand [13]. However, and despite this up trend, there has been limited published evidence to support its added value or lasting impact. On the other hand, the creative use of online platforms in surgical education, collaboration, and training [8,9,[22][23][24][25], is now increasingly been offered as an alternate to traditional face-to-face activities. This includes live surgeries, continuous surgical education, attending conference, and surgical mentoring.
Within this context, the value of travel and physical face-to-face engagements needs to be explored and defined. The aim of this paper is to address this need by examining the current trends of TSF/CTF and their future direction, in addition to providing analysis on the most valued experiences within CTF, as well as the overall professional and personal impacts.

Search terms, inclusion and exclusion criteria
Using Google and Google Scholar search engines, the following terms were searched: Surgical/ surgery travelling/ travelling fellowship, Colorectal travelling/ travel/ fellowship Surgical/surgery travel grant, Surgical/ surgery travel scholarship. We conducted a retrospective review of all TSFs, using the search terms listed above, limited to publications in the English language. Specialties outside the General Surgery domain (e.g., cardiac, plastic and orthopaedics) were excluded. When available, online Colorectal TSF (CTF) reports were identified and independently processed and analysed by two senior surgeons ( Table 1). The identification process is summarized in diagram 1.
General Surgical subspecialties (e.g., Breast and Endocrine, Hepatobiliary, and Vascular surgeries) were included in trend and timeseries analysis.

TSF data processing
For each TSF, a record was made of the host country and the year in which TSF was awarded. Countries were then grouped into nine geospecific regions as shown in Table 3. In this data set we have performed a time series analysis, detailed in the following section (Primary data analysis).

Data analysis
To account for any presumed serial correlation between years, we utilized autoregressive integrated moving average (ARIMA) time series analysis. Autoregression (AR) is the term referred to the period of autocorrelation. In our data set, the unit measure was 1 year, defined as the year in which TSF was awarded. The ARIMA and AR terms were identified using autocorrelation and partial autocorrelation graphs.
A time series dataset must be determined as stationary and nonrandom to allow effective prediction. The model's suitability was checked using the Augmented Dickey-Fuller (ADF) test. Goodness of fit was assessed by r 2 statistics.
A comparison between the total and annual percentages for each theme category was determined using chi-square test, a p-value < 0.05 was considered significant.
Data analysis was achieved using EViews 9 and IBM SPSS 25 for Windows X.

Colorectal TSF analysis
Web-based CTF reports identified were analysed. In each, surgical experiences were distilled into ten theme categories (TC), outlined in Table 2. A record was made for each TC based on intended, observed, assisted, or performed experiences mentioned in the reports. The annual frequency and distribution of host countries were determined (sentence deleted). A further analysis of the data set from 2010 to 2019 was performed to show the annual and total percentage share for each themecategory. Statistical comparison between theme categories was conducted.
The qualitative descriptive analysis consists of a summary of general motives, impressions, and impacts was recorded.

International Colorectal Travelling Fellowship (ICTF)
A separate descriptive analysis was also performed on CTSs awarded to surgeons from middle-and low-income countries. TME: Total Meso-rectal Excision, CME: Complete Meso-colic Excision, STARR: Stapled Trans anal Rectal Resection, VMR: Ventral Mesh Rectopexy, MDT: Multi-Disciplinary Team, PPH: Procedure for Prolapse and Haemorrhoids., LIFT: Ligation of Inter-sphincteric Fistula Tract.

Global distribution, annual frequency general surgery TSF
Online search yielded 489 General Surgery TSFs including 98 Colorectal TSF (CTF). Information regarding host countries were identified in 350 TSFs. The results are detailed in Table 3

Time series analysis
Our time-series data proved non-stationary by ADF test (t-statistics − 2.087839, probability 0.5314) necessitating transformation before analysis. Successful transformation was achieved using the Auto-Regressive Integrated Moving Average (ARIMA) model of (1,1,0). AR (1) indicating autocorrelation between the total number of fellows in the previous year with the number of fellows in the current year, I1 indicating a difference of (1) and a moving average (MA (0)) of 0, ADF test (t-statistics − 4.339066, probability 0.0113). The time series analysis is shown in Table 4. A regression coefficient (R 2 ) of 0.257, shows a yearon-year weak positive correlation. It implies that time alone accounts for 26 % of the variability seen with a significant p-value of 0.018 (Fstatistics).

International Colorectal Travelling Fellowships (ICTF)
The cohort of international fellows identified in this study were awarded by ASCRS and SSAT for visiting the USA (Table 1). 65 International Travelling Fellowships were awarded between 2007 and 2019, only nine colorectal ITF reports are currently available. Fellows were invited to attend the ASCRS Annual Scientific Meeting and then offered observership programs at centres of excellence in the United States. A descriptive summary of the reported impacts and limitations by international fellows is provided in Table 5.   (9), ACPGBI (5), James IV AS (3), and RCSI (9). Many organizations, including ACS, ASGBI, RCS(Ed), RCS(Eng), and RCSC with known CTF programs, have not provided online information. The figures for the USA were primarily based on international TSFs. Outside the USA, the top five countries hosting CTF were the U.K., France, Japan, South Korea and Switzerland. The average number of participating hospital-centres in each country is three (range 1-8).

Descriptive analysis of colorectal theme-categories
Distilled theme categories reveal a broad distribution of multiple interests. Recurring theme-country associations are noted. Examples include: interest in lateral pelvic wall dissection observed in Japan, robotic surgery in South Korea, assessment and management of functional bowel disorders in the UK, pelvic floor dysfunction and ventral mesh rectopexy in Belgium, LIFT and advancement flaps in the Netherlands, PPH, STARR, and Trans-STARR in Italy, Transanal TME in Spain and advanced surgical approach to IBD in the USA.
With reference to minimally invasive surgery, fellows reported new insights into unforeseen indications and scope of use. Examples include the utilization of laparoscopy and robotic surgery in pelvic exenteration, lateral pelvic wall lymph node dissection and extra-levator abdominoperineal resections. Many have also appreciated learning new operative approaches and technical skills. Much was also written on the understanding of processes and solutions applied in the healthcare system of host-countries including the patients' journey, healthcare funding, multidisciplinary involvement as well as pre-and postoperative care. Candidates also noted junior doctors' working hours as well as senior surgeon's mentoring style and support for residents and fellows.
For candidates who attended challenging and complex colorectal surgeries relating to inflammatory bowel disease, anal fistulae, pelvic floor and functional bowel disorders, and advanced colorectal malignancies, a consistent message was distilled on the value CTFs as an immersive experience. Many described the benefits of gaining valuable knowledge, learning new surgical techniques, understanding how to   negotiate operative frustration points, and refine decision-making processes.
The incentive to travel for the purpose of academic engagement varied considerably. Approximately 75-80 % of fellows attended conferences and were invited as speakers. Many forged subsequent research collaborations and some were involved in departmental scientific activities.
The importance of CTF in the personal and professional journey of surgeons was also highlighted in many reports. Considerable value was stated on the fellow-to-mentor relationship. Some utilized this prize to springboard their career prospects. Others made use of this opportunity to self-reflect and exchange ideas, pursue new friendships and collaborative relationships, and to appreciate different cultures and traditions.
No reciprocal reports were provided by host mentors, centres, or organizations, on the value or impact of TSF/CTF.

Discussion
The body of evidence supporting specialist fellowship training programmes is considerable; demonstrating significant impact on surgical proficiencies and patient health care outcomes [28][29][30][31][32][33]. Other research also points towards a consistent increase in the number of applicants pursuing surgical sub-specializations [34][35][36], matched by an increase in availability of centres offering advanced surgical fellowship training [37]. The factors contributing to these trends are multiple and complex. They include the current structure of graduate surgical training programmes, evolving health care systems and rapid advances in surgical practice. When considering surgical travelling fellowships in general, the picture is mixed. A subset of travelling surgical and colorectal fellowships exhibit a similar structure and framework to graduate training programs. Remaining TSFs, however, vary considerably in duration, structure, experience and level of immersive involvement. For the latter, this level of heterogeneity has perhaps contributed to the lack of scientific evidence evaluating its impact and validity. Nonetheless, general figures published on websites belonging to sponsoring colleges of surgery, surgical associations and societies summarized in Table 1, suggest a pattern of sustained increase in the annual number of fellows from the year 2000 consistent with other specialist training programs.
In this study, we have provided a quantitative analysis on trends of the number of fellows in TSF and CTF and their most sought-after surgical themes in colorectal surgery. We have also provided a qualitative assessment of the values, experiences and personal impacts expressed by travelling fellows from developed and developing countries.
Our results demonstrate a pre-Covid- 19 Pandemic showing an increase in the annual number of combined TSF and CTF averaging 26 % since the year 2000. The time-series analysis predicts a continued uptrend beyond the latest available data-points in 2019. The data also shows the distribution of host countries for both TSF and CTF. They are, in order of volume, the USA, Western Europe, The U.K., Australasia, Japan and South Korea.
The incentives to pursue a travelling fellowship, highlighted in this study, are multifactorial. The pursuit of technical surgical knowledge is key. This is clearly demonstrated in the results of our annual distribution of theme analysis, where a correlation was found between the timely emergence, or popularization, of a novel surgical technique, and the year of travel in which it was first recorded as theme-interest. Other incentives include the powerful perception of the added value of TSFs/ CTFs awards, as a privileged opportunity to advance one's own career.
Additional factors include, the opportunity to present completed or ongoing work of research or simply to attend conferences and forums and the ability to connect with master surgeons.
The values distilled in this review are multiple. The most sought-after theme-interests were, consistently: minimally invasive surgery (laparoscopy, robotic surgery and TaTME), the organisation of healthcare, surgical training and mentoring, multidisciplinary management of challenging colorectal cases and new approaches to pelvic floor and proctological conditions. Less quantifiable, but nonetheless frequently expressed were the powerful value of building a lasting mentor-mentee relationship, advancing surgical knowledge, gaining operative insight, embracing the opportunity to reflect and question, the ability to compare and contrast, and finally to represent one's own establishment in a public relation exercise. For international travelling surgical fellows (ITF), their experiences, highlighted in this review reveal a palpable impact on surgeons' attitude, their institutional work-flow in managing complex colorectal cases and on community-based initiatives such as screening programs. The disruption caused by the COVID-19 pandemic had effectively resulted in the suspension of TSFs/CTFs for two years. Candidates have instead explored the possibilities offered by internet-based platforms. These technologies have enabled borderless and synchronous communications, permitting a broad spectrum of virtual interactions. Substantive evidence has since emerged on their efficacy, validity, cost efficiency and broader reach [22][23][24][25]38,39]. It now continues to be adopted by many institutions in mainstream technical and non-technical surgical training [40]. The lasting impact of COVID and these technological advancement on the course of TSF/CTF should be clearer in the following years. Recent advertisements and figures published by the ECP and ASCRS suggest a continued support for CTF. 41,42 But the future may be shaped by other important factors such as cost and carbon footprint.
Travelling fellowships and international exposure offer numerous advantages, as highlighted in this review. The impact of these experiences on personal and professional development has been demonstrated, emphasizing their significance to candidates. Despite the rise of new technologies and online interactions, these traditional practices are unlikely to be disrupted in the short and intermediate term. However, a hybrid approach has emerged and is expected to continue in the near future, presenting a synergistic solution.
This review is constrained by certain limitations, including its retrospective nature, the heterogeneity and the positively biased nature narrated in post-fellowship reports. To fully realize the potential of Travelling Surgical Fellowships (TSFs) and Colorectal Travelling Fellowships (CTFs), it is imperative to collect prospective standardized feedback. Validating our findings through such feedbacks can inform future guidelines for TSFs, facilitating its standardization and uniformity of its potential.
Furthermore, it is crucial to recognize the limited understanding of the impact of Travelling Surgical Fellowships (TSFs) on inviting host surgeons, institutions, and the surgical community as a whole. Investigating this aspect is imperative to identify the short-and long-term benefits and impacts associated with hosting TSFs. Such research would provide valuable insights and could potentially contribute to the dissemination of these practices and enhance its effectiveness and global reach.
"In an increasingly digital, distance-learning, homogenous, one-sizefits-all era, the James IV Travelling Fellowship captures the essence of this immersive method of exchanging surgical knowledge and keeps it very much alive. There are some things you just can't Google." [27] Mr. Euan J Dickson, James IV AS Travelling Fellowship, 2019

Conclusion
This study provides the first comprehensive review of Colorectal Travelling Fellowships, highlighting their increasing popularity over the past two decades. The results indicate that fellows highly value surgical experiences in areas such as minimally invasive surgery, advanced multimodal management of complex surgical conditions, and interests in health care organisation and surgical education and training. It is evident from our findings that human interaction continues to be essential for fostering collegial relationships and establishing long-term connections among colleagues. To accurately assess the true value of fellowship programs, it is crucial to gather robust data, including valueadded fields based on fellows' feedback. Prospective standardized studies are necessary to further explore and validate the outcomes of these programs. Table 7 10-year distribution of Colorectal TSF themes.

Author contribution
I am the sole author of this manuscript and have contributed to all aspects of the research, including the design, data collection, analysis, and writing of the manuscript.

Declaration of competing interest
I declare that there is no conflict of interest regarding the publication of this manuscript.

Funding statement
I declare that there was no funding received for this research.

Ethical publication statement
As a literature-based review, this article is exempt.