Journal of Clinical Anesthesia 44 (2018) 1–2 Contents lists available at ScienceDirect Journal of Clinical Anesthesia Correspondence Continuous erector spinae plane block provides effective perioperative analgesia for breast reconstruction using tissue expanders: A report of two cases Keywords: Erector spinae plane block Breast cancer Breast reconstruction surgery Expander Analgesia To the editor, Breast reconstruction surgery using tissue expanders is usually associated with severe, widespread postoperative pain (ranging from T2–T3 to T6–T7) due to tissue expansion; however, there is no generally accepted ‘gold standard’ procedure for pain management. It has been reported that regional anesthetic techniques (paravertebral anesthesia) lead to a signiﬁcantly lower incidence of recurrence or metastasis of breast cancer compared to analgesia achieved by opioid administration perioperatively ; regional analgesia may be considered superior to opioid analgesia during and after surgery for cancer. In this report, we describe two cases in which continuous erector spinae plane (ESP) block was performed to provide perioperative analgesia for breast reconstruction using tissue expanders. In both cases, a written informed consent for publication was obtained. 1. Case 1 A 49-year-old woman (height 155 cm, weight 43 kg) was scheduled for right total mastectomy, sentinel node biopsy and breast reconstruction surgery using tissue expanders. After induction of general anesthesia, an ipsilateral, ultrasound-guided ESP block was performed as follows. The patient was placed in the left lateral decubitus position and a linear transducer was placed in a longitudinal orientation approximately 3 cm lateral to the T5 spinous process. An 18-gauge Tuohy needle was introduced in-plane and advanced into the interfascial plane deep to the erector spinae muscle. After negative aspiration for blood, 20 mL of ropivacaine 0.375% was injected and an indwelling catheter was placed. The catheter infusion was connected to a patient-controlled anesthesia pump that administered ropivacaine 0.2% at the rate of 8 mL/h with a 3-mL bolus and a 30-minute lockout period. General anesthesia was maintained with propofol 3.0 μg/mL (target controlled infusion: TCI) and remifentanil 0.1 μg/kg/min, and the operation was ﬁnished uneventfully. A synthetic opioid, remifentanil, was used during surgery, but none was used 0952-8180/© 2017 Elsevier Inc. All rights reserved. postoperatively, and 50 mg of loxoprofen sodium was administered at the end of the operation. The patient did not complain of pain upon recovery from general anesthesia. The patient's numerical rating scale (NRS) was 0, and the area of analgesia, as assessed by pinprick test, involved the dermatomes T2 to T8 on post operation days (POD) 1 and 2. 2. Case 2 A 47-year-old woman (height 157 cm, weight 81 kg) was scheduled for left total mastectomy, sentinel node biopsy and breast reconstruction surgery using tissue expanders. After induction of general anesthesia, the patient was placed in the right lateral decubitus position and ipsilateral ESP block and catheter insertion were performed in the same manner as described in Case 1. The dose of continuous ESP block was the same as that in Case 1. We maintained general anesthesia with propofol 2.0 μg/mL (TCI) and remifentanil 0.05 μg/kg/min; 50 mg of loxoprofen sodium was administered at the end of the surgical procedure. The patient did not complain pain upon regaining consciousness. The patient's NRS values at rest and on movement were 0 and 2–3 on POD 1 and 2, respectively, and the area of analgesia, as assessed by pinprick test, involved the dermatomes T3 to T7 on both days. The ultrasound-guided ESP block is a recently developed procedure for providing extensive thoracic analgesia . The procedure is relatively easier to perform and noninvasive, compared to thoracic paravertebral block and thoracic epidural analgesia. In both cases, ESP block provided effective analgesia without use of longer-acting opioids like fentanyl intraoperatively. Moreover, the area of analgesia was broad on POD 1–2 (T2–T8 and T3–T7 in patients 1 and 2 respectively), and the patients experienced little to no pain at rest. Our experience indicate that continuous ESP block can be considered as a ﬁrst-line analgesic method for breast reconstruction surgery using tissue expanders. Acknowledgements Funding This research did not receive any speciﬁc grant from funding agencies in the public, commercial, or not-for-proﬁt sectors. Conﬂict of interest None. Yuichi Ohgoshi, MD, Staff Anesthesiologist* Toshiaki Ikeda, MD, Senior Resident Department of Anesthesiology, International University of Health and Welfare Mita Hospital, Tokyo, Japan *Corresponding author at: 1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan. E-mail address: firstname.lastname@example.org (Y. Ohgoshi). 2 Correspondence Kiyoyasu Kurahashi, MD, PhD, Professor Department of Anesthesiology, International University of Health and Welfare Mita Hospital, Tokyo, Japan Department of Anesthesiology and Intensive Care Medicine, International University of Health and Welfare, School of Medicine, Narita, Japan 1 September 2017 Available online xxxx https://doi.org/10.1016/j.jclinane.2017.10.007 References  Exadaktylos AK, Buggy DJ, Moriarty DC, Mascha E, Sessler DI. 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