Available online 15 October 2025, 151564

No mortality difference between non-operative and operative management.

Non-operative management is linked to a higher risk of pancreatic pseudocyst.

Operative management is linked to a higher risk of iatrogenic pancreatic fistula.

Therapeutic decision hinges on a trade-off between distinct complication profiles.

Prospective registries are needed due to the very low certainty of current evidence.

Pancreatic trauma in the pediatric population is an uncommon but highly morbid injury. Its management remains controversial, with treatment strategies ranging from non-operative management (NOM) to upfront operative management (OM), primarily guided by the patient's hemodynamic stability and the integrity of the main pancreatic duct. This systematic review and meta-analysis aim to elucidate the comparative effectiveness and safety of NOM versus OM for pediatric pancreatic trauma.

Following PRISMA guidelines, a systematic search was conducted in seven major databases (including PubMed/MEDLINE, EMBASE, and Scopus) up to September 10, 2025. From 320 identified records, 17 observational studies met the eligibility criteria, comprising 1147 patients. A random-effects meta-analysis was performed to calculate pooled Odds Ratios (OR) with 95% Confidence Intervals (CI) for key outcomes, including mortality, overall complications, pancreatic pseudocyst, and fistula. Bayesian analysis was used for corroboration, and the certainty of evidence was assessed using the GRADE framework.

The analysis found no significant difference between NOM and OM for mortality (OR 0.89; 95% CI 0.48–1.66; I²=0%) or overall complications (OR 0.75; 95% CI 0.41–1.38; I²≈41%). However, a significant clinical trade-off emerged for specific complications. NOM was associated with a significantly higher risk of pancreatic pseudocyst (OR 2.56; 95% CI 1.55–4.23; I²=0%). Conversely, NOM was associated with a substantially lower risk of pancreatic fistula compared to OM (OR 0.27; 95% CI 0.11–0.69; I²=0%). Evidence for other secondary outcomes was largely inconclusive due to statistical imprecision. The certainty of evidence for all outcomes was rated as very low.

Non-operative management is a viable and safe primary strategy in selected pediatric patients with pancreatic trauma and does not appear to increase mortality. The therapeutic decision hinges on a crucial trade-off: NOM increases the risk of pseudocyst formation, while OM increases the risk of iatrogenic fistula. Despite the very low certainty of the available evidence—an inherent limitation of trauma research—these findings provide a critical framework for facilitating shared decision-making. Prospective, multi-center registry studies are urgently needed to establish more definitive guidelines.

Pancreatic trauma

Traumatic pancreatitis

Pediatrics

Surgical procedures

Conservative treatment

Meta-analysis

© 2025 The Author(s). Published by Elsevier Inc.