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Comment on: Ultrasound-guided modified pectoral plane (PECS II) block versus erector spinae plane (ESP) block for perioperative analgesia of surgical treatment of gynecomastia

To the Editor

We read with great interest the recently published article that compared the pectoral nerves block II (Pecs II) with erector spinae plane (ESP) block in patients undergoing surgical treatment for gynecomastia (Rashad and Abdelhay 2022). We wish to add a few discussions on this topic.

The authors concluded that the Pecs II block was superior to the ESP block in terms of pain intensity, analgesic doses, and opioid requirement (Rashad and Abdelhay 2022). However, while discussing the “Agreement and disagreement with the previous studies,” they stated the other way around, i.e., “ESP block consumed significantly less postoperative morphine doses than the PECS II group.” Moreover, they also cited two studies (Altıparmak et al 2019; Gad et al 2019) in support of this statement. Unfortunately, both these referenced studies do not match that sentence. Firstly, the study by (Altıparmak et al. 2019) did not compare the two techniques and analyzed the different concentrations of bupivacaine in the ESP block only. Rashad and Abdelhay (2022) should have cited another reference (Altıparmak et al 2018) that compared these two techniques. Secondly, even the correct referenced study (Altıparmak et al. 2018) as well as the study by Gad et al. (2019) observed that Pecs II block was superior to ESP block in accordance with the current study and not the other way as mentioned by Rashad and Abdelhay (2022).

The authors mentioned that the limited spread of the drug in the ESP block could be attributed to more opioid consumption in that group when compared to the Pecs II block. While this is correct, we wish to add an additional point in this regard. We must note that ESP block provided at the thoracic level (as in the case of breast surgeries) does not block the lateral and medial pectoral nerves (C5–7, C7–T1), thus resulting in a lower quality of pain relief, unlike the Pecs II block that provides relief from myofascial pain due to the disruption of pectoral muscles.

Lastly, the authors could have adopted “blinding” by making the anesthesiologists not involved in the performance of the blocks to assess the parameters.

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Pecs II:

Pectoral nerves block II


Erector spinae plane


  • Altıparmak B, Korkmaz Toker M, Uysal Aİ, Turan M, Gümüş DS (2018) Comparison of the effects of modified pectoral nerve block and erector spinae plane block on postoperative opioid consumption and pain scores of patients after radical mastectomy surgery: a prospective, randomized, controlled trial. J Clin Anesth 54:61–65.

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  • Altıparmak B, Korkmaz Toker M, Uysal Aİ, Gümüş Demirbilek S (2019) Comparison of the efficacy of erector spinae plane block performed with different concentrations of bupivacaine on postoperative analgesia after mastectomy surgery: ramdomized, prospective, double blinded trial. BMC Anesthesiol 19.

  • Gad M, Abdelwahab K, Abdallah A, Abdelkhalek M, Abdelaziz M (2019) Ultrasound-guided erector spinae plane block compared to modified pectoral plane block for modified radical mastectomy operations. Anesth Essays Res 13:334–339

    Article  PubMed  PubMed Central  Google Scholar 

  • Rashad MM, Abdelhay AA (2022) Ultrasound-guided modified pectoral plane (PECS II) block versus erector spinae plane (ESP) block for perioperative analgesia of surgical treatment of gynecomastia. Ain-Shams J Anesthesiol 14:97.

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RMS critically analyzed the published article and other related references and was a major contributor in writing the manuscript. SP contributed to writing the manuscript. All authors read and approved the final manuscript.

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Correspondence to Raghuraman M. Sethuraman.

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Sethuraman, R.M., Ponnusamy, S. Comment on: Ultrasound-guided modified pectoral plane (PECS II) block versus erector spinae plane (ESP) block for perioperative analgesia of surgical treatment of gynecomastia. Ain-Shams J Anesthesiol 15, 34 (2023).

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