Ann Thorac Surg
2021;112:1029-39
3. U.S. Department of Health and Human Services. HHS.Gov/Opioids. What
is the U.S. Opioid Epidemic? Content last reviewed on September 4, 2019.
Available at: https://www.hhs.gov/opioids/about-the-epidemic/index.html.
Accessed November 13, 2020.
4. Curtis HJ, Croker R, Walker AJ, et al. Opioid prescribing trends and
geographical variation in England, 1998–2018: a retrospective database
study. Lancet Psychiatry. 2019;6:140-150.
5. Kalkman GA, Kramers C, van Dongen RT, van den Brink W, Schellekens A.
Trends in use and misuse of opioids in the Netherlands: a retrospective, multi-
source database study. Lancet Public Health. 2019;4:e498-e505.
Erector Spinae Plane Block: A
Postoperative “Rescue” Analgesia for
Uncontrolled Pain After U-VATS
TO THE EDITOR: First described by Chin and associates1 in
2016 as an alternative technique to treat thoracic
neuropathic pain, the erector spinae plane (ESP) is an
easy paraspinal interfascial plane block that provides
somatic, visceral, and sympathetic nerve block at
multiple levels.
Interestingly, Chaudhary and collegues2 evaluated
the efficacy of ESP in video-assisted thoracic surgery
(VATS) compared with intercostal nerve block (ICB) in
controlling post-operative pain and preserving pulmo-
nary function. Indeed, the ICB is widely performed un-
der vision by surgeons3 as alternative analgesia to more
invasive blocks (paravertebral or epidural ones used
after Thoracotomy), since VATS should cause less post-
operative pain.
Chaudhary and coworkers2 showed
guarantees less acute and chronic pain, compared with
ICB, and preserves lung function.
Among VATS approaches, uniportal VATS (U-VATS)
has been widening in several thoracic centers like ours,
promising less postoperative pain and faster recovery of
the patient. In fact, U-VATS seems to be less painful than
triportal VATS3 because its incision involves only 1
anterior intercostal space (wider than posterior spaces)
without rib spreading. In our U-VATS experience,3
where the ICB is always performed, most patients have
low/absent postoperative pain with fast recovery.
Nevertheless, some patients experiment an uncontrolled
pain in the immediate postoperative period. In light of
new evidence,4 we performed ultrasound-guided, 1-shot
ESP block (10 mL of ropivacaine 7.5 mg/mL) at T5 level as
“rescue” analgesia in a subset of such patients. In our
preliminary experience, patients reported an immediate
relief of pain with improvement of chest expansion and
without opioid administration in the following 24 hours.
Recently, randomized trials4 investigated the efficacy
of ESP in VATS compared with another effective block,
the serratus anterior plane (SAP), concluding that ESP
provides better analgesia and recovery with lower
CORRESPONDENCE 1037
morbidity. In U-VATS surgery, SAP is also often used
with success thanks to the single-incision localization
(between the serratus fibers).
However, the execution of SAP block as “rescue”
analgesia after U-VATS could be quite difficult, with high
rate of failure, because of postoperative skin emphy-
sema around the surgical incision that precludes an
ultrasound-guided precise procedure. Therefore, we
think that ESP could also be a good alternative in ante-
rior VATS approaches and we would appreciate the au-
thors’ opinion on that according to their experience.
Giovanni Punzo, MD*
Department of Anesthesiology and
Intensive Care Medicine
Fondazione Policlinico Universitario A.Gemelli-IRCCS
 Cattolica del Sacro Cuore
Universita
Rome, Italy
Dania Nachira, MD*
Department of General Thoracic Surgery
Fondazione Policlinico Universitario A.Gemelli-IRCCS
 Cattolica del Sacro Cuore
Universita
Largo A. Gemelli, 8
00168, Rome, Italy
email: danynac@libero.it
Liliana Sollazzi, MD, PhD
Department of Anesthesiology and
Intensive Care Medicine
Fondazione Policlinico Universitario A.Gemelli-IRCCS
 Cattolica del Sacro Cuore
Universita
Rome, Italy
how ESP
*Drs Punzo and Nachira contributed equally to this work.
REFERENCES
1. Chin KJ, Adhikary SD, Forero M. Erector spinae plane (ESP) block: a new
paradigm in regional anesthesia and analgesia. Curr Anesthesiol Rep.
2019;9:271-280.
2. Chaudhary O, Baribeau Y, Urits I, et al. Use of erector spinae plane block
in thoracic surgery leads to rapid recovery from anesthesia. Ann Thorac
Surg. 2020;110:1153-1159.
3. Nachira D, Meacci E, Petracca-Ciavarella L, et al. Uniportal video-
assisted thoracic surgery Roman experience—a report of the first 16-month
Roman experience. J Thorac Dis. 2018;10(Suppl 31):S3678-S3685.
4. Finnerty DT, McMahon A, McNamara JR, et al. Comparing erector spinae
plane block with serratus anterior plane block for minimally invasive thoracic
MISCELLANEOUS
surgery: a randomised clinical trial. Clin Invest. 2020;125:802-810.
Erector Spinae Plane Block—Block of
Choice for Video-Assisted Thoracic
Surgery?
REPLY TO THE EDITOR: We appreciate the letter from
Punzo and colleagues1 in response to our recently
published paper.2 At our institution, the erector spinae