Turkish Journal of Surgery

Turkish Journal of Surgery

ISSN: 2564-6850
e-ISSN: 2564-7032


Erdinç Kamer, Turan Acar

Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey

Dear Editor,

We readthe article titled “Evaluation of the Alvarado scoring system in the management of acute appendicitis” by Özsoy et al. (1) published in 2017 issue (2017; 33(3): 200-204.) of the Turkish Journal of Surgery with great interest.

Acute appendicitis (AA) is probably the most common surgical emergency throughout the world. It is important to make an accurate diagnosis of AA in order to reduce the negative appendectomy rate. Therefore, taking a good medical history, physical examination, imaging tests and scoring systems have a great value.

Özsoy et al. (1) aimed to show the value of Alvarado Score (AS) in AA and to suggest a “management algorithm” according to AS in their study. After reviewing this paper, we would like to emphasizeseveral issues. First of all, it is not understood whether the study design was prospective or retrospective. If this is a prospective study, it will be appropriate to define the randomization method between the groups. The authors divided patients into 3 groups according to their Alvarado score: AS 1-4 (Group 1), AS 5-7 (Group 2) andAS ≥8 (Group 3). However, when we reviewed the literature, we found that the groups were generally divided as AS 1-4, AS 5-6 and AS 7-10 (2). The authors should explain to readers how they have classified these patients.In addition, the reasons why 14.7% of the patients in Group1 underwent surgery despite the literature recommendation of discharge instead of surgery for this group should be clarified by the authors (2). Although the authors’ main purpose was to suggest a “management algorithm” in light of their results, we could not find an algorithm in this paper.We believe that writing a “management algorithm” will be quite beneficial for the readers.

The efficiency of AS parameters for the diagnosis was given in Table 3. The reliabilityof AS in the diagnosis for AAhas already been shown in various studies (2, 3). It is also controversial that only 3 of those parameters were found significant in this study. In our opinion, creating a new table comparing Group 1 with Group 3 and Group 2 with Group 3 by determining a cut-off value will contribute more to the literature than the existing table.

Furthermore, the authors recommended that imaging tests should not be used in patients with AS> 7 in the conclusion part, whereas the correlation between imaging tests and AS was not evaluated in the study and they did not even mention which imaging methods had beenperformed in the materials-methods section. We believe that it is crucial to explain how they have reached such a conclusion.

Authors' reply

Dear editor,

We would like to thank the author’ evaluation for the manuscript.

This is a retrospective study. The demographic and clinical findings, histopathological characteristics were all retrieved from patient’s files.

There are different studies about randomization of groups in the literature (1-5). In this study, the patients were divided into 3 groups according to AS values. We used Yüksel et al. (5) recommendations since it is a recent study. In our study, the optimum cut-off value for AS in AA diagnosis was found to be 7 according to ROC curve analysis. All patients with AS of >7 was found to have histopathological appendicitis.

The negative appendectomy rate was reported as 15-30% of the patients who were operated with a diagnosis of AA (6-9). In our study, the negative appendectomy rate was 19.8%. The negative appendectomy rate was higher than the average in the groups with an AS of ≤4. Based on our findings, we agree with the recommendations put forward in the literature. In short, patients with an AS of ≤4 can be discharged and followed-up at home after informing the patient. Patients with an AS of 5-7 should be followed-up closely by using imaging methods since they probably have AA. We think that patients with an AS of ≥8 can undergo an operation without imaging methods (Figure 1).

We agree with the suggestion of creating a new table comparing Group 1 with Group 3 and Group 2 with Group 3 by determining a cut-off value. However, the study is retrospective in nature. AS components were examined, but they were not effective for surgical decision making. The limitations of the study were explained in the discussion section.

Zeki Özsoy
Department of General Surgery, Gaziosmanpaşa University School of Medicine, Tokat, Turkey

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DOI: 10.5152/turkjsurg.2017.4002017

Cite this paper as: Kamer E, Acar T. Editorial comment on: ‘Evaluation of theAlvaradoscoringsystem in the management of acute appendicitis’.Turk J Surg 2017; 33: 320-321.

Peer Review

Externally peer-reviewed.

Author Contributions

Concept - E.K., T.A., E.K., T.A.; Design - E.K.,T.A.; Supervision - E.K., T.A.; Resource -E.K., T.A.; Materials - E.K., T.A.; Data Collection and/or Processing - E.K., T.A.; Analysis and/or Interpretation - E.K., T.A.; Literature Search - E.K., T.A.; Writing Manuscript - E.K., T.A.; Critical Reviews - E.K., T.A.

Conflict of Interest

No conflict of interest was declared by the authors.

Financial Disclosure

The authors declared that this study has received no financial support.


I wish to present my special thanks to General Surgery staff for their cooperation.


  1. Özsoy Z, Yenidoğan E. Evaluation of the Alvarado scoring system in the management of acute appendicitis. Turk J Surg 2017; 33: 200-204.
  2. Ohle R, O'Reilly F, O'Brien KK, Fahey T, Dimitrov BD. The Alvarado score for predicting acute appendicitis: a systematic review. BMC Med 2011; 9: 139.
  3. Kollár D, McCartan DP, Bourke M, Cross KS, Dowdall J. Predicting acute appendicitis? A comparison of the Alvarado score, the Appendicitis Inflammatory Response Score and clinical assessment. World J Surg 2015; 39: 104-9.