Title: Predictive Model for Identification of Gangrenous or Perforated Appendicitis in Adults:
A Multicenter Retrospective Study
Version: 4 Date: 17 Jul 2024
Reviewer:  Florin Iordache
Reviewer's report:
Thank you for the opportunity to review the paper “Predictive Model for Gangrenous/Perforated
Appendicitis Identification in Adults: A Multicenter Retrospective Study” by Yun Liang et
al. This retrospective study has the merit of addressing the  issue of discriminating between
complicated/non-complicated appendectomy. The study has a significant study group, and the
statistics are properly done, but I have the following concerns:
1. Why exclude patients aged over 65? In some studies, it is a risk factor for complicated
appendicitis. Furthermore, the study of Eddama et al. (cited by the authors - ref. 13)validates
age. In the reviewed paper there were 13 patients excluded. This is an important study bias -
please address it.
2. Today, CT scan has more value than visualizing the fecalith and measuring the diameter. There
is good literature showing that fat stranding and fluid presence are correlated with complicated
appendicitis. In the study of Kim et al. (Abdominal Radiology 2021 vol 46) a diagnostic model
discriminating between the type of appendicitis their model showed an AUC of 0.81. In another
study (Cai JH et al. Helyon 2023) similar and some different parameters were used for prediction
with an AUC 0,87. The authors should compare their predictive model with those already
published.
3. There is no avoiding unnecessary surgeries as the authors stated in the second paragraph in
the discussion chapter, more likely urgent surgery, because even late results of CODA trial (ref
8 – which is a non-inferiority trial!), showed that almost 46% of those treated conservatively
needed appendectomy in a 2-year interval. The authors should comment accordingly.
Title: Predictive Model for Identification of Gangrenous or Perforated Appendicitis in Adults:
A Multicenter Retrospective Study
Version: 4 Date: 17 Jul 2024
Reviewer:  Florin Iordache
Reviewer's report:
Thank you for the opportunity to review the paper “Predictive Model for Gangrenous/Perforated
Appendicitis Identification in Adults: A Multicenter Retrospective Study” by Yun Liang et
al. This retrospective study has the merit of addressing the  issue of discriminating between
complicated/non-complicated appendectomy. The study has a significant study group, and the
statistics are properly done, but I have the following concerns:
1. Why exclude patients aged over 65? In some studies, it is a risk factor for complicated
appendicitis. Furthermore, the study of Eddama et al. (cited by the authors - ref. 13)validates
age. In the reviewed paper there were 13 patients excluded. This is an important study bias -
please address it.
2. Today, CT scan has more value than visualizing the fecalith and measuring the diameter. There
is good literature showing that fat stranding and fluid presence are correlated with complicated
appendicitis. In the study of Kim et al. (Abdominal Radiology 2021 vol 46) a diagnostic model
discriminating between the type of appendicitis their model showed an AUC of 0.81. In another
study (Cai JH et al. Helyon 2023) similar and some different parameters were used for prediction
with an AUC 0,87. The authors should compare their predictive model with those already
published.
3. There is no avoiding unnecessary surgeries as the authors stated in the second paragraph in
the discussion chapter, more likely urgent surgery, because even late results of CODA trial (ref
8 – which is a non-inferiority trial!), showed that almost 46% of those treated conservatively
needed appendectomy in a 2-year interval. The authors should comment accordingly.
Please review this paper.
user
Title: Predictive Model for Identification of Gangrenous or Perforated Appendicitis in Adults:
A Multicenter Retrospective Study
Version: 4 Date: 17 Jul 2024
Reviewer:  Florin Iordache
Reviewer's report:
Thank you for the opportunity to review the paper “Predictive Model for Gangrenous/Perforated
Appendicitis Identification in Adults: A Multicenter Retrospective Study” by Yun Liang et
al. This retrospective study has the merit of addressing the  issue of discriminating between
complicated/non-complicated appendectomy. The study has a significant study group, and the
statistics are properly done, but I have the following concerns:
1. Why exclude patients aged over 65? In some studies, it is a risk factor for complicated
appendicitis. Furthermore, the study of Eddama et al. (cited by the authors - ref. 13)validates
age. In the reviewed paper there were 13 patients excluded. This is an important study bias -
please address it.
2. Today, CT scan has more value than visualizing the fecalith and measuring the diameter. There
is good literature showing that fat stranding and fluid presence are correlated with complicated
appendicitis. In the study of Kim et al. (Abdominal Radiology 2021 vol 46) a diagnostic model
discriminating between the type of appendicitis their model showed an AUC of 0.81. In another
study (Cai JH et al. Helyon 2023) similar and some different parameters were used for prediction
with an AUC 0,87. The authors should compare their predictive model with those already
published.
3. There is no avoiding unnecessary surgeries as the authors stated in the second paragraph in
the discussion chapter, more likely urgent surgery, because even late results of CODA trial (ref
8 – which is a non-inferiority trial!), showed that almost 46% of those treated conservatively
needed appendectomy in a 2-year interval. The authors should comment accordingly.
assistant