Elective pediatric surgery: profile description of children and late referral identification

ABSTRACT Pediatric surgery receives great demand for referrals from primary care services in order to evaluate the need for surgical intervention. However access to this specialized evaluation and in intervention does not always occur at the appropriate time. This study aims to characterize the profile of pediatric patients electively operated in the western Paraná state region, between 2018 and 2020, and identify those who were lately referred to surgical evaluation. This is a descriptive, cross-sectional and retrospective study through the review of electronic medical records. The variables evaluated were sociodemographic data, information on underlying diseases, referral data, specialist assessment and surgical procedure. During this period, 410 patients underwent an elective surgical procedure, of which 289 were included in the research. The sample was predominantly male (72.3%) with a mean age of 57.9 months at the surgeons assessment and 59 months at the date of surgery. Most of the patients came from primary care (75%) and the most common pathology was inguinal hernia (39.1%). The mean time interval between referral through primary care and surgery was 4.98 months, and between the surgeons assessment and surgery was 1.21 months. Of the total sample, 77 (26.6%) patients were identified as being referred late for the surgical procedure. Knowing the profile of patients and the problems experienced in this region in relation to the care provided in pediatric surgery provides subsidies to propose improvement strategies not only for the health system in this location, but for several inner regions of Brazil in a similar situation.

System (SUS) 6 . The levels of care that make up the health services network must act in an articulated way, developing actions to guarantee the completeness of care to the user.
In this context, access to specialized care is one of the greatest difficulties of SUS, due both to the insufficient supply of diagnostic and therapeutic actions and to the modes of organization and functioning of specialized care, including, for example, the quality and quantity of referrals and requests, which generates an important overload in this care segment. Principles and guidelines should thus be considered, such as equity, transparency, timely access to services and their adequate use, based on the needs of each user, aiming at comprehensive care 7 .
One of the great challenges of primary care is deciding when to refer the patient to a specialist in secondary or tertiary care8. Regulatory action must be based on referral protocols, ordering instruments for the different levels of care complexity and on clinical protocols, which deal with the form of intervention for pathologies, supporting therapeutic decisions 7 . In order for the Primary Health Care (PHC) service to be able to organize the flow of care and referrals to specialized care for the population assigned to its territory, it is necessary to know the profile of these populations. To this end, profiling children undergoing pediatric surgery will contribute to proposing measures aimed at reducing the delay in referrals of potentially surgical patients to be evaluated by a specialist.
Furthermore, performing the surgeries within the expected age range will provide positive results in the long run, both in terms of reducing complications resulting from the delay in performing the necessary surgical correction, and in reducing family stress. This study aims to characterize the profile of pediatric patients electively operated in the Western region of Paraná, as well as to identify patients who were referred late for evaluation with the surgeon.
We assessed the age of operated patients at different times. Initially, we observed that patients' average age when referred for evaluation by the surgeon was 61 months. The average age of patients at diagnosis of the pathology by the physician who provided the initial care and who led to the referral to the specialist was 58 months. Furthermore, the mean age at the Talini Elective pediatric surgery: profile description of children and late referral identification specialist's assessment was 57 months and on the date of the surgery, 59 months.
We also assessed age separately by pathology, considering the most frequent ones ( Table 3). The comparison between the children who needed to undergo surgery due to phimosis and those who underwent inguinal herniorrhaphy showed a statistically significant difference when analyzing age at the preoperative consultation, specialist assessment, and age at the time of surgery (p<0.001 for each).  (Table 4).
Of the total, 77 (26.6%) patients were identified as being referred late for the surgical procedure,  with an incidence of 4% of full-term boys and up to 30% of premature babies 14 . Despite the possibility of spontaneous descent of the testicle into the scrotum after birth, its occurrence proved to be uncommon after three months of life 15 and rare after six months 14 . The age at which the surgical intervention is performed is an important predictive factor for the future fertility of these patients. Furthermore, patients with cryptorchidism have an increased risk of developing testicular tumors, especially those treated surgically after puberty 16  In this study, the average age at referral of patients with cryptorchidism for evaluation by the specialist was 71.5 months, and in the evaluation by the surgeon, 56.4 months, averages well above what is considered ideal for the treatment of this pathology.
We investigated whether patients with cryptorchidism already had any findings during surgery that could be compatible with the delay in referral, and we found that in 7.3% the testicle was small in relation to what was expected for their age. According to the findings, the hypothesis of risk of testicular atrophy and infertility as a future implication was present in 7.8% of cases, however there was no previous measurement of testicular size to characterize objective values for this subjectively observed reduction.
According to current consensus, surgery should be performed not after 18 months of age 15 . In our sample, the mean age at the time of orchidopexy was 58.3 ± 54.9 months. A recent population cohort study concluded that for every six months of delay in performing orchidopexy, there is a 6% increase in the risk of developing cancer, a 5% increase in the need to use technologies for assisted This study has several limitations, among which we can mention the data collected retrospectively (secondary data), the information from a single health Talini Elective pediatric surgery: profile description of children and late referral identification condition whose treatment delay has an important negative impact in the future.
We suggest that the shortage of professionals in the specialty and lack of coordination in the primary care network, which makes articulation between the network services difficult, can be raised as contributing factors to the difficulties encountered in this process between referral and surgery. bearing in mind that these are pathologies that are not always generally known to everyone, and issues such as appropriate ages for referral to a specialist may go unnoticed by these professionals, in addition to the establishment of new referral flows and prioritization of patients with pathologies in which the delay in surgery has greater future implications for patients.

CONCLUSION
The characterization of pediatric surgical patients showed that the majority were male and that the most frequently identified pathology was inguinal hernia. After epidemiological characterization of the study participants regarding referral, specialist assessment, and surgical procedure, 26.6% of patients were referred late for surgery. The pathology most frequently associated with delay in referral, evaluation by a specialist, and surgery was cryptorchidism, a