Endoscopic retrograde cholangiopancreatography (ERCP) is the gold-standard therapeutic procedure for managing biliary obstruction of both benign and malignant etiology. Biliary drainage via stent placement is essential in cases of cholestasis, cholangitis, or obstructive jaundice. Plastic stents (including straight and pigtail designs) and self-expandable metal stents (SEMS) are the two main types used.Plastic stents are commonly used due to their ease of insertion, cost-effectiveness, and suitability for temporary drainage especially in benign strictures, peri-procedural biliary decompression, or patients awaiting surgery. The double-pigtail plastic stent (DPT) has become the preferred choice due to its ability to minimize migration, anchor securely across strictures, and reduce perforation risk .

In malignant biliary strictures, studies suggest multiple stents (especially SEMS) can offer better patency and less dysfunction than a single stent.

Some advantages Hypothesized for Double DPT Stents are

·         Enhanced biliary drainage due to increased stent lumen availability.

·         Lower risk of stent occlusion or early dysfunction.

·         Reduced need for early re-intervention.

·         Better anchorage in dilated CBDs, reducing risk of migration.

However, some concerns with double Stents are

·         Increased procedural time.

·         Technical difficulty in placing two stents.

·         Theoretical increase in cost and risk of post-ERCP pancreatitis or cholangitis.

There is currently no randomized trial comparing single vs double DPT stents in a homogenous population undergoing ERCP for biliary drainage—whether in benign strictures, pre-operative decompression, or palliative settings. There is lack of consensus or guideline recommendations on optimal number of plastic stents in ERCP for non-hilar obstruction.