Figure 2.9 . Liver damage 3/6 according to Ishak (Patient N20-0204706)
Figure 2.10 . Liver damage grade 4/6 according to Ishak (Patient A10-0047088)
Figure 2.11 . Liver damage 5/6 according to Ishak (Patient N18-0396611)
Figure 2.12 . Liver damage 6/6 according to Ishak (Patient N19-0208006)
2.6.4 Data collection
Data were collected according to sample medical records (Appendix).
ICG clearance and preserved liver volume were measured and calculated by the same group and according to a unified procedure.
2.7 Research process
Data collection: from October 2016 to the end of March 2021, in which, secondary data was collected from October 2016 to before July 9, 2019, primary data was collected from July 9, 2019 to the end of March 2021.
Data processing: from April 2021 to the end of June 2021.
Writing thesis and two thesis-related articles: July 2021 to December 2021.
2.8 Methods of data presentation and analysis
Data were processed using IBM SPSS 26.0 and R 4.0.5 software.
Continuous variables will be presented in quartiles with Q1 being the 25th percentile, Q2 being the median, Q3 being the 75th percentile, minimum and maximum values: age,
body surface area (BSA), ICG-R15, ICG-PDR, serum albumin, serum bilirubin, INR, RLV/SLV, RLV/P, number of days in hospital. When comparing between groups, variables will be presented using Q2 quartiles (Q1 - Q3).
- If the variable has a normal distribution, the difference between two groups will be tested by T-test, between multiple groups by One-Way ANOVA test and post hoc analysis by Tukey's HSD method.
- If the variable is not normally distributed but the logarithm is normally distributed, the difference between two groups will be tested by T-test, between multiple groups by One-Way ANOVA test for the logarithm of the variable. This method will find more differences between groups than non-parametric tests.
- If the variable is not normally distributed and the logarithm is also not normally distributed, the difference between two groups will be tested by Mann-Whitney U test, between multiple groups by Kruskal-Wallis test.
Qualitative or ordinal variables: gender, Child-Pugh score, Child-Pugh classification, extent of liver resection, method of liver resection, degree of cirrhosis on histopathology, nature of liver tumor on histopathology, surgical complications, complications of liver failure, liver failure classification, will be presented as proportions, tested for differences by Chi-Square test or Fisher's Exact test.
In the first research objective , we found the correlation between the continuous variable ICG clearance (ICG-R15) and the ordinal variable Ishak score cirrhosis level using Spearman correlation.
In the second study objective , we compared ICG clearance and Child-Pugh score in assessing liver function before liver resection based on two criteria:
- First criterion: compare ICG clearance with Child-Pugh score in predicting the degree of liver cirrhosis on histopathology according to Ishak score.
- Second criterion: compare ICG clearance with Child-Pugh score in predicting liver failure complications after liver resection.
In the third research objective , we investigated the relationship between two preoperative liver function assessment tools, ICG clearance (ICG-R15) and preserved liver volume (RLV/SLV), and complications of liver dysfunction after major hepatectomy. From there, we built a model to estimate the risk of liver failure after major hepatectomy based on a logistic regression model.
In the study, we built two prognostic models to estimate two outcome variables: the degree of liver fibrosis on pathology according to the Ishak scale and the rate of liver dysfunction after major hepatectomy.
- Independent variables were selected to be included in the prognostic model based on clinical practice regarding the application of these variables in predicting outcome variables.
- Model to estimate the degree of liver cirrhosis on pathology according to the Ishak scale:
This model was built based on an ordinal logistic regression model for the outcome variable. Based on two demographic variables (gender, age) and preoperative liver function tests (ICG-R15, serum bilirubin concentration, INR, platelet count), three models to estimate the Ishak score were built as follows:
+ Univariate model based on ICG-R15 values only.
+ Multivariate model based on all 6 variables above.
+ The multivariate model is reduced by the backward stepwise variable selection method based on the AIC (Akaike Information Creation) selection criterion.
- Model to estimate the rate of liver failure after major liver resection:
This model was built based on the logistic regression model. Based on demographic variables (age, sex), clearance (ICG-R15), pathological cirrhosis degree (Ishak score) and preserved liver volume (RLV/SLV), two models to estimate the risk of liver failure after liver resection were built as follows:
+ Multivariate model based on all 5 variables above.
+ The multivariate model is reduced by the backward stepwise variable selection method based on the AIC (Akaike Information Creation) selection criterion.
- The reduced multivariate model is built with the aim of making the model easy to apply in clinical practice while still maintaining the same efficiency as the full multivariate model.
- The model performance indicators are validated and optimized using bootstrap resampling with 1000 iterations.
2.9 Ethics in research
ICG has been approved for use in patients by the Vietnamese Ministry of Health since May 2016 (Appendix). Ho Chi Minh City University of Medicine and Pharmacy Hospital is the only hospital in the country that is authorized to use ICG in assessing liver function before liver resection.
All patients were explained the benefits of ICG clearance in assessing liver function, possible side effects and allergic reactions, as well as the cost of the test. Only when the patient agreed, the test was performed. Patient information was recorded and included in the study only with the patient's consent.
The topic was approved by the Ethics Council in Biomedical Research of Ho Chi Minh City University of Medicine and Pharmacy on July 9, 2019, code number 316/DHYD-HDDD (Appendix).
Chapter 3. RESULTS
During the period from October 2016 to the end of March 2021, 340 patients meeting the inclusion criteria were included in the study.
3.1 Sample population characteristics
3.1.1 Gender, age, skin area
The male:female ratio is 4.6 (279:61).
Patient age is normally distributed, median is 59 years old, Q1 is 51 years old, Q3 is 66 years old, youngest is 17 years old, oldest is 86 years old.
Skin area has a normal distribution, median is 1.66m 2 , Q1 is 1.56, Q3 is 1.75, smallest is 1.18, largest is 2.03.
3.1.2 Hepatitis
Table 3.1. Hepatitis status of patients
Hepatitis
Quantity | % | |
Hepatitis B | 206 | 60.6 |
Hepatitis C | 51 | 15.0 |
Co-infection with hepatitis B and C | 1 | 0.3 |
No hepatitis | 82 | 24.1 |
Total | 340 | 100 |
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of the islanders. Therefore, this indicator will be divided into two sub-indicators:
a1. Natural tourism attractiveness a2. Cultural tourism attractiveness
b. Tourist capacity
The two island communes in Quan Lan have different capacities to receive tourists. Minh Chau Commune is home to many standard hotels and resorts, attracting high-income domestic and international tourists. Meanwhile, Quan Lan Commune has many motels mainly built and operated by local people, so the scale and quality are not high, and will be suitable for ordinary tourists such as students.
c. Time of exploitation of Quan Lan Island Commune:
Quan Lan tourism is seasonal due to weather and climate conditions and festivals only take place on certain days of the year, specifically in spring. In Quan Lan commune, the period from April to June and from September to November is considered the best time to visit Quan Lan because the cultural tourism activities are mainly associated with festivals taking place during this time.
Minh Chau island commune:
Tourism exploitation time is all year round, because this is a place with a number of tourist attractions with diverse ecosystems such as Bai Tu Long National Park Research Center, Tram forest, Turtle Laying Beach, so besides coming to the beach for tourism and vacation in the summer, Minh Chau will attract research groups to come for tourism combined with research at other times of the year.
d. Sustainability
The sustainability of ecotourism sites in Quan Lan and Minh Chau communes depends on the sensitivity of the ecosystems to climate changes.
landscape. In general, these tourist destinations have a fairly high level of sustainability, because they are natural ecosystems, planned and protected. However, if a large number of tourists gather at certain times, it can exceed the carrying capacity and affect the sustainability of the environment (polluted beaches, damaged trees, animals moving away from their habitats, etc.), then the sustainability of the above ecosystems (natural ecosystems, human ecosystems) will also be affected and become less sustainable.
e. Location and accessibility
Both island communes have ports to take tourists to visit from Van Don wharf:
- Quan Lan – Van Don traffic route:
Phuc Thinh – Viet Anh high-speed boat and Quang Minh high-speed boat, depart at 8am and 2pm from Van Don to Quan Lan, and at 7am and 1pm from Quan Lan to Van Don. There are also wooden boats departing at 7am and 1pm.
- Van Don - Minh Chau traffic route:
Chung Huong high-speed train, Minh Chau train, morning 7:30 and afternoon 13:30 from Van Don to Minh Chau, morning 6:30 and afternoon 13:00 from Minh Chau to Van Don.
f. Infrastructure
Despite receiving investment attention, the issue of infrastructure and technical facilities for tourism on Quan Lan Island is still an issue that needs to be resolved because it has a direct impact on the implementation of ecotourism activities. The minimum conditions for serving tourists such as accommodation, electricity, water, communication, especially medical services, and security work need to be given top priority. Ecotourism spots in Minh Chau commune are assessed to have better infrastructure and technical facilities for tourism because there are quite complete and synchronous conditions for serving tourists, meeting many needs of domestic and foreign tourists.
3.2.1.4. Determine assessment levels and assessment scales
Corresponding to the levels of each criterion, the index is the score of those levels in the order of 4, 3, 2, 1 decreasing according to the standard of each level: very attractive (4), attractive (3), average (2), less attractive (1).
3.2.1.5. Determining the coefficients of the criteria
For the assessment of DLST in the two communes of Quan Lan and Minh Chau islands, the students added evaluation coefficients to show the importance of the criteria and indicators as follows:
Coefficient 3 with criteria: Attractiveness, Exploitation time. These are the 2 most important criteria for attracting tourists to tourism in general and eco-tourism in particular, so they have the highest coefficient.
Coefficient 2 with criteria: Capacity, Infrastructure, Location and accessibility . Because the assessment area is an island commune of Van Don district, the above criteria are selected by the author with appropriate coefficients at the average level.
Coefficient 1 with criteria: Sustainability. Quan Lan has natural and human-made ecotourism sites, with high biodiversity and little impact from local human factors. Most of the ecotourism sites are still wild, so they are highly sustainable.
3.2.1.6. Results of DLST assessment on Quan Lan island
a. Assessment of the potential for natural tourism development
For Minh Chau commune:
+ Natural tourism attractiveness is determined to be very attractive (4 points) and the most important coefficient (coefficient 3), so the score of the Attractiveness criterion is 4 x 3 = 12.
+ Capacity is determined as average (2 points) and the coefficient is quite important (coefficient 2), then the score of Capacity criterion is 2 x 2 = 4.
+ Exploitation time is long (4 points), the most important coefficient (coefficient 3) so the score of the Exploitation time criterion is 4 x 3 = 12.
+ Sustainability is determined as sustainable (4 points), the important coefficient is the average coefficient (coefficient 1), so the score of the Sustainability criterion is 4 x 1 = 4 points
+ Location and accessibility are determined to be quite favorable (2 points), the coefficient is quite important (coefficient 2), the criterion score is 2 x 2 = 4 points.
+ Infrastructure is assessed as good (3 points), the coefficient is quite important (coefficient 2), then the score of the Infrastructure criterion is 3 x 2 = 6 points.
The total score for evaluating DLST in Minh Chau commune according to 6 evaluation criteria is determined as: 12 + 4 + 12 + 4 + 4 + 6 = 42 points
Similar assessment for Quan Lan commune, we have the following table:
Table 3.3: Assessment of the potential for natural ecotourism development in Quan Lan and Minh Chau communes
Attractiveness of self-tourismof course
Capacity
Mining time
Sustainability
Location and accessibility
Infrastructure
Result
Point
DarkMulti
Point
DarkMulti
Point
DarkMulti
Point
DarkMulti
Point
DarkMulti
Point
DarkMulti
CommuneMinh Chau
12
12
4
8
12
12
4
4
4
8
6
8
42/52
Quan CommuneLan
6
12
6
8
9
12
4
4
4
8
4
8
33/52
b. Assessment of the potential for humanistic tourism development
For Quan Lan commune:
+ The attractiveness of human tourism is determined to be very attractive (4 points) and the most important coefficient (coefficient 3), so the score of the Attractiveness criterion is 4 x 3 = 12.
+ Capacity is determined to be large (3 points) and the coefficient is quite important (coefficient 2), then the score of the Capacity criterion is 3 x 2 = 6.
+ Mining time is average (3 points), the most important coefficient (coefficient 3) so the score of the Mining time criterion is 3 x 3 = 9.
+ Sustainability is determined as sustainable (4 points), the important coefficient is the average coefficient (coefficient 1), so the score of the Sustainability criterion is 4 x 1 = 4 points.
+ Location and accessibility are determined to be quite favorable (2 points), the coefficient is quite important (coefficient 2), the criterion score is 2 x 2 = 4 points.
+ Infrastructure is rated as average (2 points), the coefficient is quite important (coefficient 2), then the score of the Infrastructure criterion is 2 x 2 = 4 points.
The total score for evaluating DLST in Quan Lan commune according to 6 evaluation criteria is determined as: 12 + 6 + 6 + 4 + 4 + 4 = 36 points.
Similar assessment with Minh Chau commune we have the following table:
Table 3.4: Assessment of the potential for developing humanistic eco-tourism in Quan Lan and Minh Chau communes
Attractiveness of human tourismliterature
Capacity
Mining time
Sustainability
Location and accessibility
Infrastructure
Result
Point
DarkMulti
Point
DarkMulti
Point
DarkMulti
Point
DarkMulti
Point
DarkMulti
Point
DarkMulti
Quan CommuneLan
12
12
6
8
9
12
4
4
4
8
4
8
39/52
Minh CommuneChau
6
12
4
8
12
12
4
4
4
8
6
8
36/52
Basically, both Minh Chau and Quan Lan localities have quite favorable conditions for developing ecotourism. However, Quan Lan commune has more advantages to develop ecotourism in a humanistic direction, because this is an area with many famous historical relics such as Quan Lan Communal House, Quan Lan Pagoda, Temple worshiping the hero Tran Khanh Du, ... along with local festivals held annually such as the wind praying ceremony (March 15), Quan Lan festival (June 10-19); due to its location near the port and long exploitation time, the beaches in Quan Lan commune (especially Quan Lan beach) are no longer hygienic and clean to ensure the needs of tourists coming to relax and swim; this is also an area with many beautiful landscapes such as Got Beo wind pass, Ong Phong head, Voi Voi cave, but the ability to access these places is still very limited (dirt hill road, lots of gravel and rocks), especially during rainy and windy times; In addition, other natural resources such as mangrove forests and sea worms have not been really exploited for tourism purposes and ecotourism development. On the contrary, Minh Chau commune has more advantages in developing ecotourism in the direction of natural tourism, this is an area with diverse ecosystems such as at Rua De Beach, Bai Tu Long National Park Conservation Center...; Minh Chau beach is highly appreciated for its natural beauty and cleanliness, ranked in the top ten most beautiful beaches in Vietnam; Minh Chau commune is also home to Tram forest with a large area and a purity of up to 90%, suitable for building bridges through the forest (a very effective type of natural ecotourism currently applied by many countries) for tourists to sightsee, as well as for the purpose of studying and researching.
Figure 3.1: Thenmala Forest Bridge (India) Source: https://www.thenmalaecotourism.com/(August 21, 2019)
3.2.2. Using SWOT matrix to evaluate Quan Lan island tourism
General assessment of current tourism activities of Quan Lan island is shown through the following SWOT matrix:
Table 3.5: SWOT matrix evaluating tourism activities on Quan Lan island
Internal agent
Strengths- There is a lot of potential for tourism development, especially natural ecotourism and humanistic ecotourism.- The unskilled labor force is relatively abundant.- resource environmentunpolluted, still
Weaknesses- Poorly developed infrastructure, especially traffic routes to tourist destinations on the island.- The team of professional staff is still weak.- Tourism products in general
quite wild, originalintact
general and DLST in particularalone is monotonous.
External agents
Opportunity- Tourism is a key industry in the socio-economic development strategy of the province and Van Don economic zone.- Quan Lan was selected as a pilot area for eco-tourism development within the framework of the green growth project between Quang Ninh province and the Japanese organization JICA.- The flow of tourists and especially ecotourism in the world tends toincreasing
Challenge- Weather and climate change abnormally.- Competition in tourism products is increasingly fierce, especially with other localities in the province such as Ha Long, Mong Cai...- Awareness of tourists, especially domestic tourists, about ecotourism and nature conservation is not high.
Through summary analysis using SWOT matrix we see that:
To exploit strengths and take advantage of opportunities, it is necessary to:
- Diversify products and service types (build more tourism routes aimed at specific needs of tourists: experiential tourism immersed in nature, spiritual cultural tourism...)
- Effective exploitation of resources and differentiated products (natural resources and human resources)
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3.1.3 Preoperative liver function
3.1.3.1 Liver function according to Child-Pugh scale
Serum albumin has a normal distribution.
Serum bilirubin has a right-skewed distribution, logarithm has a normal distribution. INR has a right-skewed distribution, logarithm has a non-normal distribution.
Table 3.2. Liver function tests in the Child-Pugh scale
Blood tests
Median | Q1 | Q3 | Smallest | Biggest | |
Albumin (g/L) | 40.60 | 37.80 | 42.90 | 28.40 | 49.70 |
Bilirubin (mmol/L) | 12.20 | 9.50 | 14.74 | 3.59 | 35.00 |
INR | 1.05 | 1.00 | 1.11 | 0.89 | 1.79 |
Table 3.3. Liver function according to Child-Pugh scale
Classify
Point | Quantity | % | |
A | 5 | 306 | 90.0 |
6 | 31 | 9.1 | |
B | 7 | 3 | 0.9 |
Total | 340 | 100 | |
3.1.3.2 Platelet count
Platelet count has right-order distribution, logarithm has normal distribution, median is 214 G/L, Q1 is 164 G/L, Q3 is 275 G/L, minimum is 46 G/L, maximum is 719 G/L.
3.1.3.3 ICG Purity
ICG-PDR has a normal distribution.
ICG-R15 has a right skewed distribution, logarithm has a normal distribution.
Table 3.4. ICG clearance
ICG Purity
Median | Q1 | Q3 | Smallest | Biggest | |
ICG-PDR (%) | 19.50 | 16.60 | 19.50 | 4.20 | 43.80 |
ICG-R15 (%) | 5.40 | 3.30 | 8.30 | 0.10 | 53.30 |