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  • br surgery despite a suboptimal success rate and the


    surgery, despite a suboptimal success rate and the fact that resection is often performed without the benefit of intraoperative guidance and visualization.
    Ultrasound, mostly endoscopic, has gained an important role in diagnosing patients with a suspicion of pancreatic cancer and has the benefit of being able to perform fine needle aspirations during the same proce-dure (Iqbal et al. 2012). Laparoscopic ultrasound can be performed during staging laparoscopy prior to surgical exploration (Allen et al. 2016). During surgery, intrao-perative ultrasound (IOUS) can be useful in helping determine vascular involvement in patients with border-line-resectable pancreatic cancer (de Werra et al. 2015; D’Onofrio et al. 2007). By offering real-time imaging data, IOUS provides direct feedback regarding the lesion’s extent and vascular involvement. This informa-tion can then be used to guide the surgical strategy and approach. In addition, because it uses a high-frequency probe in direct contact with the organ, IOUS provides superior spatial resolution and Artesunate compared with CT and magnetic resonance imaging (MRI) (Sun et al. 2010). Although IOUS may be useful during surgical exploration and resection of pancreatic cancer, few stud-ies have used this technique to assess tumor extension and subsequent IOUS-guided resection (Tamm et al. 2013). A study by Kolesnik et al. (2015) retrospectively examined the effect of IOUS on surgical interventions, reporting that their surgical strategy changed because of IOUS in 30% of the patients, most of them owing to the detection of hepatic metastases. Except for this study, IOUS is not routinely applied during resections of pan-creatic cancer, and the added value is scarcely described.
    Here, the benefits of performing IOUS with respect to surgical strategy in patients with pancreatic or periam-pullary tumors undergoing surgical exploration was evaluated. In addition, the results of preoperative radio-logic imaging, IOUS and pathologic evaluation of the resected specimen were compared.
    In the Leiden University Medical Center (LUMC), preoperative radiologic imaging was performed on all patients with a suspect lesion in the pancreas. A CT scan was obtained for all patients; in some patients, an addi-tional MRI scan was performed. If it was deemed neces-sary, a preoperative cytology sample was obtained and used for histopathologic confirmation of a malignancy. The patients were evaluated by the multidisciplinary pan-creatic team in order to determine whether surgery was a treatment option, and if so, whether a vascular resection should be considered. Each resection began with a staging laparoscopy in order to exclude the presence of metastases. 
    In patients who went on for an exploratory laparotomy, IOUS was performed. In this study, consecutive Artesunate patients who underwent surgical exploratory laparotomies for pan-creatic or periampullary cancers (including duodenal, dis-tal bile duct or ampulla of Vater cancers) at the LUMC from June 2016 through June 2017 were included. Patients who underwent surgery for a neuroendocrine tumor were excluded from this study. The use of IOUS during the sur-gical procedure is standard of care in the LUMC, and in this study, only the impact of IOUS was evaluated, there-fore, a waiver was given for the need for informed consent by the Medical Ethics Committee of the LUMC.
    The primary objective was to evaluate the effect of IOUS on surgical strategy; therefore, the effect of IOUS on the surgical strategy and/or any additional informa-tion obtained from IOUS was defined as follows: (i) no value, (ii) additional information regarding tumor locali-zation, (iii) additional information regarding vascular contact or (iv) the ability to waive surgery.