High-grade pancreatic trauma in children: comparison of conservative and surgical management in two case reports

Background: Blunt pancreatic trauma in the pediatric population is a rare but high-stakes clinical challenge, accounting for approximately 0.2–9% of abdominal injuries. While non-operative management (NOM) is the gold standard for low-grade injuries, the management of American Association for the Surgery of Trauma (AAST) Grade III and IV injuries, specifically those involving the main pancreatic duct, remains controversial. Evidence is currently divided between conservative strategies, endoscopic interventions, and early surgical resection or reconstruction. Case Presentation: This report describes two cases of high-grade pancreatic trauma (Grade IV) in adolescent males resulting from bicycle handlebar injuries. Both patients presented with epigastric pain and significantly elevated serum pancreatic enzymes. Initial imaging (CT and MRI) confirmed near-full or complete-thickness parenchymal lacerations at the head-body or body-tail junctions. In Case 1 , a 10-year-old boy underwent endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic duct stenting three days post-injury. He was successfully managed with a conservative regimen including total parenteral nutrition (TPN) and was discharged on day 24, although long-term follow-up revealed persistent ductal leakage requiring restenting. In Case 2 , a 15-year-old boy also underwent ERCP and stenting; however, his course was complicated by the development of infected peripancreatic fluid collections and clinical deterioration. He subsequently underwent a delayed surgical reconstruction (Roux-en-Y pancreaticojejunostomy) on day 27, resulting in a rapid recovery and complete resolution of ductal leakage. Conclusions: Management of high-grade pediatric pancreatic trauma requires a highly individualized approach. While ERCP-guided stenting can facilitate successful non-operative management in selected cases, it does not guarantee the avoidance of surgery. These cases demonstrate that while a "watch-and-wait" strategy is feasible, clinicians must maintain a low threshold for surgical intervention if conservative measures fail. Furthermore, the persistence of ductal leakage in asymptomatic patients highlights the necessity of rigorous, long-term follow-up to optimize functional outcomes.