Pigtail Stent Procedure and Patient Care
Double pigtail stents are the preferred option for internal drainage procedures, with plastic stents without intervening side holes between the ends being recommended for optimal outcomes. 1
Procedure Overview
Indications and Patient Selection
- Pigtail stents are commonly used for internal drainage in various conditions including pancreatic pseudocysts, leaks after bariatric surgery, and ureteral obstruction 1, 2
- These stents are particularly beneficial in high-risk surgical patients who cannot tolerate more invasive procedures 1, 3
- Multidisciplinary involvement including an endoscopist, interventional radiologist, and surgeons is required in complicated cases to decide on the best approach to drainage 1
Procedural Technique
- The procedure typically involves:
- Initial imaging (CT or MRI) to delineate anatomy and plan the approach 1
- Prophylactic antibiotics are recommended before the procedure and should be continued post-procedurally 1
- Fluoroscopy guidance is essential for monitoring guidewire position and stent placement 1
- Puncture of the target area using an appropriate gauge needle (typically 19-gauge for pancreatic procedures) 1
- Introduction of a guidewire (0.035 inch or 0.025 inch with floppy tip) through the needle 1
- Dilation of the tract to accommodate the stent 1
- Placement of one or two plastic double pigtail stents to maintain patency 1
Stent Selection
- For pancreatic procedures, 7 Fr straight plastic stents without intervening side holes are most commonly used 1
- Double pigtail plastic stents are preferred for internal drainage as they have lower migration rates compared to straight stents (9% vs 23%) 1
- Short and smaller-caliber stents (7F 3 cm or 7F 5 cm) are recommended to minimize damage to surrounding structures 1
- Polyurethane stents (6 Fr, 24 or 26 cm) are commonly used for ureteral applications 4
Post-Procedure Care
Immediate Post-Procedure Management
- Patients should be monitored for signs of complications including bleeding, infection, or perforation 1
- Continued antibiotic therapy is recommended to prevent infection 1
- Pain management may be necessary as loin discomfort occurs in approximately 19% of patients with ureteral stents 2
Follow-up and Stent Management
- Routine stent exchange should be performed every 2-4 weeks until the cavity has contracted (usually <2 cm in size) 1
- For ureteral stents, removal is typically performed after approximately 14 days 4
- Regular imaging is necessary to monitor response to therapy 1
- Markers of successful therapy include:
- Ability to tolerate diet
- Decrease in the size of any perigastric cavity
- Resolution of the original condition 1
Complications and Their Management
Common Complications
- Urinary tract infection (31-61% depending on stent material) 2
- Trigonal irritation (18-29% of cases) 2
- Loin discomfort (19% of insertions) 2
- Stent migration (reported in approximately 5% of cases) 2
- Obstruction (rare, approximately 2% of cases) 2
Special Considerations
- Single pigtail suture stents (SPSS) may be considered as an alternative to double pigtail stents in ureteral applications, as they are associated with reduced stent-related symptoms and improved quality of life 4, 5
- For bariatric surgery complications, endoscopic internal drainage using pigtail stents is considered an effective alternative to fully covered self-expanding metal stents, providing higher success rates, shorter treatment duration, and lower adverse event rates 1
- Careful monitoring of all patients with pigtail catheters is recommended due to the potential for complications 2
Special Applications
Bariatric Surgery Complications
- For leaks and fistulae after bariatric surgery, endoscopic internal drainage by pigtail plastic stents is considered an effective treatment 1
- Double pigtail stents are preferred when there is a small-caliber tract connecting a leak orifice to a collection 1
Pancreatic Pseudocysts
- One or two plastic double pigtail stents should be inserted to maintain the patency of the cystogastrostomy after EUS-guided drainage 1
- Technical and clinical success rates of over 90% have been reported with double pigtail stents for pseudocyst drainage 1, 6
By following these guidelines for pigtail stent placement and management, clinicians can optimize outcomes while minimizing complications for patients requiring this intervention.