Title page
Title: A novel, protective and optimal, flexible liver retraction method with clipping andsuturing techniques in laparoscopic gastrectomy for gastric cancer
Short running title: Protective and optimal liver retraction

Comment [SE1]: Please note that the title isunnecessarily long and contains unnecessary
words. There are no criteria for use of the word
“optimal.” In addition, while the meaning of“suturing” is self-evident, that of “clipping” isnot. Please consider this title instead: “A novel
liver retraction method in laparoscopic
gastrectomy for gastric cancer.”
If you choose to use it, please change it in the
cover letter as well.
Comment [SE2]: Please note that thatrunning title serves only to help the reader
keep their place in the journal. A better
running title would be “Liver retraction during
laparoscopy.”

Authors

Keywords: Gastric cancer · Laparoscopic gastrectomy · Liver retractor

Comment [SE3]: Please note that the journal
instructs to mention the names of all theauthors. Also, it requests the “highest
academic degree.” To be mentioned for them.

Comment [SE4]: Please place this statement
under the Acknowledgement section after
Conclusion to meet the journal guidelines.

Conflict of interest:
There are no funding sources for this study or any associated financial conflicts.

Comment [SE5]: Please note that the journal
does not ask for the word count on the title
page. Please consider deleting this. If you
choose to include it anyway, be sure to checkthe count in the final draft.

Total words: 2794

ABSTRACT
Background: Retracting the lateral liver segment during laparoscopic distal gastrectomy isimportant to achievefor achieving an optimal surgical field. However, excessive force onmay
injure the liver may cause liver injuries during perioperative period and a, causing temporaryrise inabnormalities ofin liver function tests after laparoscopic surgery. Since weWedeveloped a new liver retraction method, we verified and assessed its safety andusefulnessutility.
Patients and mMethods:
This is a retrospective analysis using prospectively compiledWe retrospectively analyzed
records in our surgical database in our institute. Consecutiveof consecutive surgical patients
1

Comment [QA6]: Please note that it’s better
not to use the word “prospectively” here.
Almost by definition, such clinical databases
are “prospectively” designed, that is, thedecision is made to establish a database
containing particular items of clinicalinformation. Data from subsequently treatedpatients are then included in the database.
However, studies based on such previously
compiled data almost always retrospective, as
you have correctly stated regarding your study.
The study is designed to take advantage of thedata that has already been collected. These
datamining studies are often very helpful inproviding information that would be very
difficult to obtain in a prospective study. The
reason for avoiding the word “prospective” todescribe the database is that some readers
may be confused, reading both “retrospective”
and “prospective” in the same sentence.

who underwent laparoscopic distal gastrectomy (LDG) for 229 early gastric cancer, wereextracted from the database, and the perioperative data were obtained.. We divided the 229
patients into two groups dependingbased on whether ourthe liver retraction technique (theFlexible LIver-method used, either flexible liver retraction method with Clippingclippingand Suturing techniquessuturing (FLICS group))) or Nathanson’sthe Nathanson retractor

Comment [SE7]: Please note that it’sunnecessary to indicate the letters included in
the abbreviation. Also, the word “method” isunnecessary in the middle of the term.

(NR group) was used. After that, one). One-to-one propensity score matching was performed
to align patient backgrounds, and match patients, resulting in the records of 53 pairs of cases
were extracted. Serum AST, ALT, CRP and T-Bill were measured atfrom the database.

Operative and postoperative days 1, 3, 5, 7 and outcomes were assessed, including following
the values of serum liver enzymes, total bilirubin, and C-reactive protein until postoperative
day 30.
Results: There waswere no significant differencedifferences in patient backgroundandcharacteristics or preoperative examination data after PSM. There was no addition orchange of Liver retractor.data in the two groups. No serious complications associated with

Comment [SE8]: Please note that it’sunnecessary to keep repeating PSM.

liver retractorsretraction were observed in both groups. No postoperative liver failure wasobserved in all patients.either group.
Conclusions: Our new liver retraction technique provided an optimal surgical field without
inducing post-operative liver dysfunction. It is a simple, safe protective new, and effective

Comment [SE9]: Please note that “optimal” is
OK here, since there would be generalagreement on what that means whendescribing visualization of the surgical field.
That is different than its use in the title todescribe a new method.
Comment [QA10]: This statement is notsupported by your data. How “simple” is theprocedure? Does it include less steps or easier
to handle? Did you test that it is simpler thanthe previous procedure?

liver retraction technique.
(301 words)
Key words: Laparoscopiclaparoscopic gastrectomy, Gastricgastric cancer, Liverliver
retraction, Internal Organ retractorRetractor, Nathanson’s retractor, propensity score-matchedanalysis.
2

Comment [SE11]: This needs to becapitalized if it is the actual brand name of the
instrument. If not, it should be in lower case.

INTRODUCTION
Laparoscopic distal gastrectomy (LDG) has been widely used for treating patients within

Comment [SE12]: It’s preferable to introduce
the abbreviation denoting a specific extent ofgastrectomy later in the text, as this is a moregeneral term.

Japan since 1991 to treat gastric cancer since 1991 in Japan [1].
[Other text deleted]
ThereforeTo avoid this problem, we have devised and enforceda liver retraction
method combining Internal Organuse of an internal retractor with sutures to help lift up by
suture.the organ, which we designated flexible liver retraction with clipping and suturing
Comment [SE13]: It seems better tointroduce this designation here rather than
waiting until the Methods.

(FLICS).
MATERIALS AND METHODSPatients and characteristics
This is a retrospective analysis using prospectivelyWe retrospectively analyzed patient
records compiled in our institution's surgical database in our institute. All patients were given
sufficient explanations and written informed consents. Consecutive. Records of consecutive
surgical patients who underwent laparoscopic distal gastrectomy (LDG) for gastric cancer,
were extracted from the database, and the. The following data were obtainedcollected: patientcharacteristics (age, sex, performance status, American Society of Anesthesiologists PhysicalStatus Classification [ASA-PS,], height, weight, body mass index [BMI, calculated as kg/m2],

Comment [QA14]: Regarding informed
consent, please state precisely what theconsent was given for, likely either for thesurgical procedure—which of course isstandard—or for inclusion of the medical
record in the database—if that was actually
done. It is highly unlikely that the patientsgave specific consent for inclusion in thisretrospective study. That is rarely done
because the data used is anonymous. Informed
consent is generally waived for retrospective
studies, so it is rather odd to see it mentioned
here unless it is described more specifically.
Either state specifically what was consented toor do not mention consent at all.

tumor size, and histology), body weight, body mass index (BMI, weight in kg divided byheight in meters squared (kg/m2))), preoperative tumor data (clinical T status, clinical N
status, clinical Stagestage, Lauren classification, presence or absence of pre-operativeand
preoperative treatment, pre-operative with endoscopic submucosal dissection), preoperativelaboratory data (the ALB (values (serum albumin), PT (, prothrombin time), CRP (, C-reactive protein), γ-GTP (Gamma [CRP], gamma-glutamyl transpeptidase), T-Bil (Total
3

Comment [SE15]: Please check that thiscorrectly conveys the intended meaning. Thisis the only preop treatment listed in Table 1.
Comment [SE16]: Only abbreviations thatwill be used again in the text and which standfor complex terms should be used. The words“albumin,” “prothrombin time,” and “bilirubin”
don’t need to be abbreviated. Subsequent usesof the latter don’t need the word “total,” asyou’ve already stated here that you mean total
bilirubin. (English does not require repetitionof adjectives once the term is clearly
understood.).

Bilirubin), surgical outcomesoutcome including intraoperative events (surgical approach,
operative time and, and immediate intraoperative immediate complications (if any)),),
postoperative course and laboratory tests of liver function, and mid-term and long -term
outcomes. TNM staging was based on the Japanese Classification of Gastric Carcinoma, 3rdEnglish Edition [18].
. Finally, patients who satisfied inclusion criteria were divided into the FLICS

Comment [SE17]: Most journals require that
an abbreviation should be spelled out at its
first occurrence in the abstract as well as in
the text followed by the abbreviation inparentheses. Thereafter, only the abbreviation
may be used. However, if the abbreviation is on
the journal's list of approved abbreviations,this need not be done. Similarly, please checkfor any other abbreviations used in the
manuscript.

group and the NR group. The clinical characteristics and perioperative outcomes werecompared between the two groups after propensity score matched (PSM).

(A, B, or C).

Comment [QA18]: Since this has an entire
paragraph explaining the procedure below,
there is no need to mention it here.

Liver retraction method during LG at our hospitalmethods
Nathanson retractor
In use of Nathanson Liver Retractor, the liver retractor isThe NR was inserted close to thexiphoid process and then placed near the hepatic hilushilum under the lateral segment of theliver. Basically, Retractor The retractor was fixed during surgery, and fixation was changed
when or repositioned as necessary to provide an adequate surgical field deployment
accompanying Liver retraction was necessary. In addition, when . If the pressure applied wasstrong, enough to cause congestion and ischemic findings were observed, weakenedor signs

Comment [QA19]: Please check that thiscorrectly conveys the intended meaning. The
original was unclear. Instruments andapparatus can be deployed in the surgical field.
The surgical field itself is not “deployed.”of ischemia, the pressure ofon the liver was weakened.

Details of the FLICS procedure are describedshown in Figure 2. When using Along with theComment [SE20]: Please check that thisrevised paragraph correctly conveys theintended meaning. We believe the revision
appropriately describes what is very nicely
represented in Figure 1.

Internal Organ Retractor, 48mm Straight48 mm straight needle 2-0 PLOLENE prolene

Comment [SE21]: Please note that Figure 1
is not cited in the manuscript and hence thecitation of all the figures should be ensured.

Flexible liver- retraction method with clipping and suturing techniques (FLICS)techniquesutures (Ethicon Endo-Surgery, Cincinnati, OH, USA) waswere used for traction.
UnderDuring pneumoperitoneum, puncture the right hypochondrium was punctured and lift
the hepatic crown lifted to the right temporal side with using 2-0 PLOLENE.the suture. After
4

Comment [QA22]: Please note that this thebest term to use in all subsequent mention in
the description of the procedure. In general,
generic terms are preferred once theappropriate proprietary information has been
supplied. But using the word “suture”
throughout this description is particularly
important since it is part of the name you havegiven your procedure, FLICS.

dissection of the lesser omentum, Internal Organ Retractorthe retractor was inserted into oneof the 12- mm trocars, and clipped to the cut edge of lesserthe omentum was grasped by theapplicator.. Liver retraction wad finishedwas accomplished by towing from outsideexternal
traction on the bodysutures.
[Other text deleted]
It was performed using a logistic regression model andwith the following covariates: Age,
Sexage, sex, ASA-PS, BMI, histology, preoperative laboratory data(ALB, PT,

Comment [SE23]: Please check that thiscorrectly conveys the intended meaning. Since“clipping” is a key term in the name of yourmethod, it should be used explicitly indescribing the technique.
Comment [QA24]: In the Conclusion section,
you claimed that this new method is simple,
however, you do not compare it properly withNathanson retractor. How long(minutes)
it takes to accomplish the new procedure?

(albumin,prothrombin time, CRP, AST, ALT, T-Bil, bilirubin, and ALP), preoperative treatment,
Location,with endoscopic submucosal dissection, Lauren classification, and preoperative

clinical stage.

Comment [SE25]: Please check that thiscorrectly conveys the intended meaning. This
was listed (without defining ESD) in Table 1.
Specific information like this should not bementioned in a table without inclusion in the
text.

[Other text deleted]
Elevations of serum liver enzyme in blood test was enzymes were evaluated based on
CTCAE andon the basis of the Common Terminology Criteria for Adverse Events Version[22], with an abnormal value was defined as ≥3 times the upper limit of normal value [22]..
Statistical analysis
All statistical calculations were performed with JMP® PRO software (JMP version 13.1.0,
SAS Institute, Cary, NC, USA). All values were two- tailed, and P- values <0.05 wereconsidered significant. We used a caliper width of 0.2 of the pooled standard deviation of thelogit of the propensity score for PSM.
RESULTSpatient Patient characteristicss after PSM analysis
The Figure 3 depicts the study flow chart is described in Figure 3.. Between 2012
January 2012 and 2016 December 2016, a total of 1,432 patients with gastric cancer patients
5

Comment [QA26]: Please note that precise
definitions are required for all the possible
liver outcomes, including “damage,”“dysfunction,” and “failure,” and perhaps aswell even for “inflammation.” This is necessary
in part. Elevated enzymes of course are not ameasure of function but rather of damage tohepatocytes, which may or may not be
associated with impaired synthetic or
metabolic function of the liver as a whole. Such
imprecision may not matter clinically, since weusually understand when we are talking aboutdamage and/or dysfunction. But in a reportsuch as yours, every outcome must be carefully
defined along with the way it was measured.
This is true even if none of the serious
outcomes actually occurred. It would be best to
do this in the Methods section, so that theterms needn’t be explained in the Results.
Technically, they should also be defined at thefoot of Table 2. We assume a low albumin
and/or a high prothrombin time would havebeen considered evidence of dysfunction.
Please, however, don’t make your readers
assume what you mean.
Comment [SE27]: Please ensure that thisconcept is correctly expressed. We are notfamiliar enough with the details of PSM toknow the correct way to state it.

were admitted to institute. During this period,our institution, of whom 434 patients who

Comment [SE28]: Please note that the figure
405 in Fig. 3 was apparently incorrect and has
been changed.

underwent Laparoscopic gastrectomyLDG for clinical early-stage gastric cancer (cT1N0M0,
Clinical Stage clinical stage I) were identified in a retrospectively maintained database. The
reasons). Reasons for exclusion criteria before PSM analysis were as follows: multiple ofrecords from the study included other organ resections (n= = 65), overa higher clinical stage
Ⅱ (n= = 67), use of other liver retraction techniques (n= = 85). In addition to the above, thepatients with ), or the presence of chronic liver damage andor a history of alcohol abuse orComment [SE29]: Please note that thisdirectly contradicts the statement above thatthe initial 434 patients identified all had
clinical stage 1 disease. Please correct thediscrepancy.

liver disease such as of hepatitis B virus, hepatitis C virus, and acute viral hepatitis were
excluded from the study. Finally, 160 LDG with A, B, or C.
After PSM, the FLICS and 69 with the NR patients were enrolled in this study.

Comment [QA30]: Please consider deletingthese two sentences. Data in the figure should
not be repeated in the text. There is no point inincluding the second sentence at all, since itmerely repeats the method, not the result. I
suggest replacing this part with “Figure #shows the exclusion criteria…”

The clinical characteristics and short-term and long-term outcomes were compared
between the two groups after PSM analysis. A totalrecords of 106 patients with laparoscopic
distal gastrectomywho had undergone LDG for early gastric cancer were included in the
study;, 53 patients (50%) were included in the FLICS group, and the remaining 53 patients

Comment [SE31]: The percentage ismeaningless, since you deliberately matchedpatients one-to-one.

were included in the NR group.
The surgical outcomes of patients undergoing the FLICS group and NR group are detailed in(Table 2. In the comparison of surgical characteristics, the ) demonstrated a significantly
shorter median operationoperative time was shorter in the FLICS group than in the NR group(224 min [140-300 min] vs. 262 min [191-336 min], P< < 0.001). Both techniques provided a

Comment [SE32]: Please note that data
should not appear in both text and table. The
numbers are easier to read in the table, so they
are superfluous here.

satisfactory view of the working fieldssurgical field during laparoscopic distal gastrectomy
andLDG. There were no intraoperative complications required any treatments relating toretraction of the liver. Curative resection (R0) was achieved in all patients. The number oflymph nodes retrieved did not differ significantly between the two groups (P = 0.185).
6

Comment [SE33]: Please note that these twosentence were moved to this paragraph. They
are about outcome, not complications, so they
did not belong in their original place in thenext paragraph on complications.

Surgical complications classified asMore cases of Clavien-–Dindo grade II or

higher are described in Table 2. Concerning early postoperative complications, more cases (7cases, 13.2%)) were observed in the NR group than in the FLICS group (7 cases, 13.2% vs. 3
patientscases, 5.7%), but the difference was not statistically significant (p=P = 0.097) (Table2). One patient in the NR group (1.9%) had a Clavien-–Dindo class III or higher
complications, whereas no patients in the FLICS group. In the NR group, one case ofcomplication (anastomotic leakage requiredrequiring reoperation. ) compared with none in
the FLICS group. No liver dysfunction was found in both groups. Curative resection (R0)
was performed in all patients. No significant difference in number of retrieved lymph node
was observed between the two groups (p=0.185). There was no 30-day or either group. There
was no in-hospital or 30 day mortality or postoperative liver failure in either group.
Parameters of liver Liver damage and inflammatory statusor inflammation
After PSM analysis, there was There were no significant difference between two
groupsdifferences in the patient’s baseline levelsresults of each liver function tests.
Circulating

at baseline between the two groups. ALT and AST levels increased significantly

from baseline within 24 hours following operationssurgery in each group. The levels of
serum ALT on both groups. On postoperative day (POD) days 3, 5, and 7, both serum ALT(Fig. 4a) and AST (Fig. 4b) levels were statistically significantsignificantly higher in the NR
group than in the FLICS group (Fig. 4a). Furthermore, levels of serum AST on POD 3, 5 andComment [SE34]: Please note that mentionof the Clavien-Dindo grades of complications isconfusing in both text and table. It isparticularly difficult to understand thereference to the patient with the anastomotic
leak as having a “grade III or higher”
complication. Please specify the exact
grade—was it III, IV, or V? (You may havechosen a cutoff of ≥class III for statisticalanalysis, but when describing the only one that
occurred, the grade should be described
precisely.) If that complication was the only
one that was grade III (or higher), were all theothers grade II? (If so, they presumably would
have required drug treatment other than withthe medications allowed for grade I
complications.) That seems to be what isindicated in the text, but it should not be
stated there that they were “grade II or higher.”
Or were some the complications listed in Table
2 grade I and some grade II? Please clarify
these various reference to the Clavien-Dindo
classifications. One option for Table 2 would beto eliminate the Clavien-Dindo grade III item
listed in the table but include a footnote with
“Overall surgical complications” stating thatthe anastomotic leak was grade III but allothers were grade II (or grade I or II, if that iscorrect).
Comment [SE35]: Please consider rounding
the percentages to integers. When n is <100,using a decimal place implies a greater degreeof precision than is possible.
Comment [QA36]: What is the definition of“liver dysfunction.”? This should be statedeither in the methods or at least at the bottomof the table. I suspect you mean disrupted
production of albumin or coagulation factors.
However, unless it is stated clearly, it isconfusing to read that there was “no liver
dysfunction” but the liver enzymes were
elevated.
Comment [SE37]: Please note that this word
is unnecessary. We do not measure ALT or AST
anywhere else.
Comment [QA38]: Please note that thisabbreviation is unnecessary in the text.
Having stated “postoperative days” here, every
subsequent reference to “day” or “days” will be
understood as meaning after the operation. It’s
fine to use “POD” in the figures if you want, asthat is clearly defined in the legend.

7 were significant higher in the NR group than in the FLICS group (Fig. 4b). Peak of. On theother hand, the totalTotal bilirubin levels became the highest on POD 1 and gradually
decreased thereafterwere also elevated in the first few days, but the levels did not differ
significantly between groups (Fig. 4d).4c). The CRP showed the same trend as has a7

Comment [SE39]: Please note that this wastrue only for the FLICS group. The graphclearly shows the level in the NR grouppeaking on day 2. It’s better not to try todescribe everything in detail in the text, since
the figures show the results so clearly.

trajectory similar to that of the AST and ALT, and values, with the elevation in the FLICS
group remainedremaining significantly lower than that in the NR group (P= = 0.0038) 004)
(Fig. 4d).
DISCUSSION
The present study evaluated a demonstrated that FLICS, our new flexible liver retraction
method without, was associated with only minimal transient elevation of liver enzymes anddid not cause liver injury. During laparoscopic gastrectomyLDG, it is important to establish agood operative field and ensure an adequate working space.

Comment [SE40]: Please be consistent in thenumber of decimal places that you report.
There’s no need to be so precise. In fact, somejournals limit it to two decimal places. The sizeof the p value is not that important. It is either
significant or not significant depending on thesignificance level you defined.
Comment [QA41]: The Discussion is
expected to begin with a clear statement of the
major findings of your study. Readers areaware of the study question that was stated(although not in question form) at the end of
the Introduction. When they reach the
Discussion, they expect to see the answer. The
Discussion should not repeat the Introduction.
We have edited the Discussion as written, butplease consider revising it to begin with themain findings followed by further discussion of
two to three points you consider mostimportant. Please eliminate the repetition of
information that was already stated in the
Introduction.

Furthermore, investigation of hepatic injury on postoperative CT caused by use of
Nathanson Liver Retractor duringIn a study using computed tomography, liver abnormalities
were seen after use of the NR in 14 of 52 (27%) patients who had undergone laparoscopic
gastrectomy for cancer and 2 of 11 (18%) who had had laparoscopic upper gastrointestinal
surgery revealed some liver abnormality in 27% of LG performed cases and 18% of bariatricsurgery [28]. Such damage to the liver is caused by the persistentPersistent strong
exclusionretraction of the liver, occurring without noticing can result in damage that goes
unnoticed intraoperatively [8]. To date, variousVarious liver retraction methods have been
done and reported to reduce the damage to the liver [12, 17, 29, 30]. Kitajima et al. [17]suggested that reducingliver damage could be prevented when using the NR by limiting theduration of liver retraction and moving the position of, periodically repositioning the retractor,
or releasing it intermittently could avoid physical pressure by Nathanson Liver

Comment [SE42]: Please note that it is better
not to state “naked” percentages. Please
include number whenever possible. The 27%
for those undergoing cancer surgery is asomewhat firmer proportion than the 18% who
underwent bariatric surgery, simply because of
the difference in the numbers. Care is usuallytaken with prospective studies to include
enough numbers to yield adequate statisticalpower. This is often not possible inretrospective studies. That does not mean thatsuch studies are invalid. But we should becautious about generalizing from small
numbers. By including the numbers fromreference you cite, you help the reader
understand how much weight to put on thefinding.
Comment [SE43]: Please check that thiscorrectly conveys the intended meaning. The
original was quite unclear, and the reference’s
Abstract didn’t mention this point. (We did nothave access to the full article.) The meaning of“exclusion of the liver” was unclear. I imagine
it refers to excluding it from the surgical field
but nonsurgeons (such as myself) might notunderstand it.
Comment [SE44]: Please note that the
rewording of this sentence. The original was inpart copied verbatim from the Abstract’s
conclusion. Word-for-word copying must be
avoided unless included in quotation marks.
However, it’s better to restate the ideas in yourown words.

Retractor.releasing it. Although they demonstrated that their technique iswas safe andComment [QA45]: It is necessary to be more
specific here and provide details on why it wasdifficult.

usefuleffective, it is technically difficult to arrangeprepare, and it is necessary to set up theComment [SE46]: Please note that we havedeleted this clause as it was completely unclear.
Would this correctly convey what you meant:“Intermittent release of tension was also
required.”?

hepatic relief again during surgery. . Our retractionFLICS method can be continuously carry8

out steady operative field deployment in orderdeployed to mobilize the liver to the patient's
upper right side of the patient, but , allowing a clear surgical field. It is adaptable by changing
the traction on the sutures, allowing adjustment as needed of fixation of the liver is done withleeway, so adaptability is high enough that as well as normal respiratory variation remains.
[Other text deleted]
The absence of elevation offact that increases in liver enzymesenzyme and CRP
levels were less marked in the FLICS than the NR group confirms that FLICS is a proof that
Comment [SE47]: Please check that thiscorrectly conveys the intended meaning. The
final clause was understandable. Also, it isincorrect to indicate an absence of enzyme and
CRP increases in the FLICS group. What’s
important is that the peak levels were lower
than in the NR group.

oursafer retraction method is a compulsive excretion method against the liver..
We believe that the overall reliability of our results is enhanced by the one-to-one
matching of thisthe study are very accurate bygroups using PSM to adjust the backgroundfactors as much as possible. Moreover, since this method is simple, stable and safe, it isconsidered to be very useful., which should have reduced the influence of unknown

Comment [SE48]: The limitations of thestudy have been described well. Study findings
may be limited to variability in surgeon
expertise. This limitation is not listed

confounders.
Acknowledgments
Table 1 Baseline characteristics of one-to-one propensity score-matched patients who

Comment [SE49]: Please acknowledge all thepeople who has helped you in completion ofthis research and have contributed in someways to come up with a novel outcome.

underwent laparoscopic distal gastrectomy for gastric cancer
FLICS group (n = 53)

NR group (n = 53)

Comment [SE50]: P, p, P, or p are acceptable

P value symbols, but one should be chosen and usedconsistently throughout the text, figures, andtables.

Age (years)

67 (34–79)

66 (27–91)

11 (20.8%):42 (79.3%):0

11 (20.8%): 42 (79.3%):0

ASA-PS(1:2:3)

0.994

1.000
(0%)

(0%)

[Other text deleted]
BMI: body mass index, cT: clinical T stage, cN: clinical N stage, ESD: endoscopic
9

Comment [SE51]: Please check whether any
P value of 1.000 should be stated. Generally a
P of 1.0 or 0.0 is considered impossible.

Comment [SE52]: All first-time use
abbreviations in main text or peripheral text
must be defined.

submucosal dissection,
Table 2 Operative and postoperative outcomes in patients who underwent laparoscopic distal
gastrectomy for gastric cancer
FLICS group (n = 53)

NR group (n = 53)

P value

Reoperation0

1 (1.9%)0.237

Postoperative hospital stay (days)

9.1 ± 1.8

15.1 ± 7.9< 0.001 discount this item in discussing the study

Overall surgical complications

Comment [SE53]: Please note that you

3 (5.7%)20 (37.7%)< 0.001

Clavien–Dindo grade >III0

1* (1.9%)

0.237

Liver dysfunction

0

0

0.237

limitations. Please consider deleting it fromthe table. If not, please at least mention it in
the text of the Results, e.g. “Although the
FLICS group had a shorter mean hospital stay,changes in hospital policy during the study
period may have influenced this result.”
Comment [SE54]: Please note that this item
was indented. When left aligned, it appearedthat it referred to all the items indented below
it. However, it might be best to delete this itemfrom the table entirely.
Comment [SE55]: As noted above in the text,
this required definition.

Organ damage (including liver
0

0

1.000

injury)Comment [SE56]: Please note that this is
unclear. Do you mean “gross liver injury”? The
fact that enzyme levels were elevated indicatesat least microscopic injury.

Comment [SE57]: Please note that thejournal requests that figure legends be brief,
with no more the 4 or 5 lines. We have revised
them to shorten them as much as possible.

Figure legendsLegends
Figure 1. Described Schematic of the flexible liver retraction with clipping and suturingmethod of handling 2-0 PLOLINE in extracorporeal operation. (a).
Figure 2. Our procedure of. Flexible liver retraction with Internal Organ retractor

Comment [QA58]: Please consider reversing
panels a and b in the figure, as well as thedescriptions written here in the legend. The
intraabdominal schematic should come first.
The external tension only makes sense when
one understands how the sutures are situatedinternally.

the right temporal side (b-c). After dissection of lesser omentum.

Comment [SE59]: Please consider
rearranging the panels so that a–c are the top
row, d–f the middle row, and g–i the bottom
row. Because readers of English normally readfrom left to right, the natural tendency is also
to look at a figure with multiple panels thesame way. It’s initially a bit confusing for thesequence of steps to be oriented verticallyrather than horizontally.

[Other text deleted]

Comment [SE60]: Please note that figure 2 is
not been cited in the text. Please check.

Puncture theclipping and suturing in situ during laparoscopic distal gastrectomy. (a–c) The
right hypochondrium and lift is punctured by the suture needle and the hepatic crown lifted toComment [SE61]: Please check that thiscorrectly conveys the intended meaning. There
was no description for panel a.

10