{'fraction_non_alphanumeric': 0.027080581241743725, 'fraction_numerical': 0.01023778071334214, 'mean_word_length': 5.194274028629857, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Letter: TIPSS improves muscle mass indices in patients with cirrhosis and severe portal hypertension

We read with great interest the article by Artru et al,1 a retrospective study of consequences of TIPSS on the body composition of patients with cirrhosis with severe portal hypertension. The authors reported that MELD score and sarcopenia assessed by transversal right psoas muscle thickness (TPMT)/height were independently associated with 6-month mortality in patients with cirrhosis undergoing TIPSS. The authors used TPMT/height, which was found to predict mortality in patients with cirrhosis independently of MELD score2; total psoas muscle area (TPMA), which was found better than skeletal muscle index (SMI) at L3 level3; and visceral and subcutaneous fat surfaces (VFS and SFS) as markers of sarcopenia. However, several issues need to be discussed. First, the baseline TPMT/height, TPMA and SFS were higher in patients without TIPSS dysfunction than their counterparts. Does this imply that patients with more severe sarcopenia at baseline are more prone to develop TIPSS dysfunction? Second, severe hepatic encephalopathy (HE) has been described in 26.2% of the cohort. However, it would be interesting to know the percentage of patients developing HE in the groups—“most severely sarcopenic” and “less severely sarcopenic,” as Nardelli et al found HE incidence to be more in sarcopenic patients.4 Moreover, there was a significant difference in baseline TPMT/height, TPMA and SFS between patients who underwent TIPSS procedure for recurrent ascites than for gastrointestinal bleeding (GIB). Was the incidence of HE significantly different in the two groups? Third, the survival benefit was similar between the ascites and GIB groups, despite a higher MELD score in the latter. The median MELD and Child-Pugh scores for the entire cohort were 11.4 and 8, respectively, whereas 15 (17.6%) and 32 (37.64%) of the GIB cohort had MELD score above 13 and 18, respectively. The authors have attributed the similar survival in the GIB and ascites groups to their consideration of early and salvage TIPSS, which is contradicted by a recent RCT5 and multi-centre study, which found that early TIPSS was only beneficial in Child C patients.6 In the present study, we noticed poor muscle mass in the ascites group and higher MELD score in GIB group. So, a possible explanation might be an almost similar MELD-Sarcopenia score,7 leading to a similar survival advantage in both groups. We congratulate the authors for conducting this study, highlighting the consequences of TIPSS placement on the body composition of patients with cirrhosis. The study highlights that TIPSS improved muscle mass indices, and its extent was dependent on the radiological patency and dysfunction of TIPSS. Future research should focus on the prospective evaluation of various aspects of sarcopenia and frailty assessment like muscle strength, quality, quantity and physical performance for better understanding of the beneficial effects of TIPSS.