Non-Operative Management of Pediatric Pancreatic Trauma: Single Tertiary-Center Outcomes and the Role of ERCP

In pediatric pancreatic trauma, non-operative management (NOM) is standard for low-grade injuries (American Association for the Surgery of Trauma [AAST] I–II), while its role in high-grade lesions (AAST III–V) remains debated. Endoscopic retrograde cholangiopancreatography (ERCP) for ductal decompression is emerging as a bridging strategy. We performed a retrospective cohort study at a tertiary center, including children with pancreatic trauma (2011–2025). NOM was offered to hemodynamically stable patients. ERCP was used to place a ductal stent when needed and feasible. Operative management (OM) was reserved for instability, NOM failure, or associated injuries. Twenty children were included: 6/20 low-grade, 14/20 high-grade. NOM was adopted in 14/20. Among low-grade (4/14), 1/4 ERCP stenting was performed and 1/4 pseudocyst developed. Among high-grade (10/14), 9/10 ERCP were performed, with successful stenting in 5/9; 3/10 pseudocysts and 1/10 hematoma occurred. Overall, NOM complications were 35%, with a median total parenteral nutrition (TPN) duration of 16 days and a length of stay (LoS) of 28 days. OM was performed in 6/20. Subtotal pancreatectomy was required in 2/6, complicated by pseudocyst (1/2) and multivisceral necrosis (1/2). In 4/6, OM addressed associated injuries, with no pancreatic complications. Overall, OM complications were 33% (100% when considering pancreas-specific surgery), with a median TPN duration of 12 and LoS of 23 days. Pancreatic complications were managed conservatively or through minimally invasive endoscopic/percutaneous interventions, without the need for surgery. No pancreatic insufficiency occurred, and no deaths were recorded. In this single-center cohort, NOM was feasible in selected hemodynamically stable children, including high-grade injuries, with pancreatic complications managed without further open surgery. ERCP may offer ductal assessment and decompression in selected cases, helping avoid resection and preserve pancreatic parenchyma—an important consideration in children to prevent pancreatic insufficiency. Optimal outcomes require a multidisciplinary team in a tertiary pediatric center.