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

Background: 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. Materials and Methods: 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. Results: 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. Conclusion: 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.