Showing posts with label GI Surgery. Show all posts
Showing posts with label GI Surgery. Show all posts

I have always enjoyed interacting with surgical residents and one of the first questions the young resident who enters surgery asks me is “ How do I study during residency?” Studying during a tough surgery residency is not easy at all. The biggest hurdle will be your seniors and colleagues who will discourage you from picking your books. The long hours, lack of sleep and abusive seniors  just compound things. But one fact we forget is - studying in residency is not a privilege, it's a duty. Acquiring knowledge so that you can treat your patients appropriately is a fundamental duty. 

This article will be a continuation to Part I of being an amazing surgical resident. 




The best surgical atlas an Indian resident can have is the patient himself. The good caseload in most Indian centres means that there is no dearth of surgical material. The optimal way to start studying is to read about the cases in the ward everyday.     The moment a case is admitted in the ward, pick up your Washington Manual of Surgery and start reading about it. The Washington Manual can be used as an e-book on your phone or tab. The Washington Manual of surgery is a small and concise handbook that doesn’t delve too much into theoretical aspects of surgery but merely lists out the concepts, diagnosis and management of a particular problem. Residents who can afford to shell out significant chunks of money can also spend on UptoDate. UpToDate is one of the best resources a resident can subscribe to. 

Keep in touch with recent research. Just type in the keywords on NCBI/Pubmed website and checkout the most appropriate research paper. Even if time doesn’t permit you the read the entire paper, read the abstract and try to understand it. 


The operating theatre can be quite intimidating as a first year resident. One of the best ways to come out unscathed out of the OR is to read well before surgery. Use Farquharson's Textbook of Operative General Surgery to read upon on the operating steps. If you have time to read the previous night, use Fischer's Mastery of Surgery 7th edition. Fischer’s is a fantastic resource which explains the anatomy and the surgery in detail. For a first year resident, it might seem like a humongous task to go through it. But the effort you put into understanding the concepts in Fischer’s will reflect on your operating table. 

For understanding the basic principles of surgery use Kirk’s Basic Surgical Techniques 6th edition . This book will teach you the methods of knot tying, suturing, fixing a drain and inserting a chest tube. 

However the best resource for operative surgery is YOUTUBE. The absolute wealth if content YouTube offers you is unsurpassed and the only hurdle will be in dis time ting between good quality content and useless videos. 

The NCCN guidelines are the most important resource a resident can use before treating a patient with a malignant condition 

YOUTUBE CHANNELS TO FOLLOW: - The official channel for Learning General Surgery. The ultimate resource on surgical knowledge especially after the lockdown lecture series. LGS videos are extremely well curated

by Dr GD Sharma and Dr Patta Radhakrishna - Basics of surgery - essential for every resident - Surgery basics explained in simple terms - SAGES channel. Follow for high quality laparoscopy training - Operative surgical oncology by Dr Marimuthu of Thanjavur, Tamil Nadu - Follow the Ukrainian maestro Dr Baydo for daredevil laparoscopy - Dr Omedary teaches us how to tie surgical knots - Dr Ashwin’s laproscopic Hernia videos are a must watch

I can keep talking about wonderful surgeons on YouTube. Really soon we will do a separate exhaustive post on YouTube channels for surgery residents. 


Bailey and Love Short Practice of Surgery, 27th edition - Read basic aspects of surgery and urology from bailey. You need nothing more for final exams and also NEET SS

Sabiston Textbook of Surgery, 20th edition - GI Surgery is best read from Sabiston,. It is quite exhaustive and an absolute deligh to read. Residents interested in GI surgery should never complete residency without reading  Sabiston. 

Schwartz Principles of Surgery, 11th edition - Breast and Thyroid chapters are extremely detailed and thorough in this masterpiece. A definite must-read. 



Clinical Surgery Pearls 3rd edition by Dr Dayananda Babu   This book is the living soul of every resident preparing for final year exams. For clinical surgery, this is no-brainer. You should definitely purchase the hard copy. 

Bedside Clinics in Surgery 3rd edition by Dr Makhan Lal Saha - This beauty of a book is a lifesaver in final year examinations. Certain chapters like abdomen examination are never omitted. 

A Manual On Clinical Surgery by S.Das 14th edition. This book is now in its 14th edition but shall never go out of favour. You would be committing a sin if you don't read ulcer and swellings from this evergreen book. Note: Even if you possess an older edition, it doesn’t matter - Nothing ever changes in successive editions. 

Separate posts will cover books that GI surgery, Onco surgery, Neurosurgery and Plastic aspirants should buy.


I used to read Bailey during my PG days and would always wish that I has an application on which I could solve MCQs so that I could simultaneously prepare for NEET SS. There were a couple of web based options but none were good for daily use in the ward. I ended up developing the SURGTEST app with a group of friends so that residents could use a handy app that would work even at low internet speeds in dimly lit, dungeon-like wards with a whole host of network issues. The general surgery question bank with more than a thousand questions based on Bailey and Love 27th edition are exhaustive and a must-have for every first year surgery resident. The questions are arranged topic wise and will help you revise core topics at ease. The Onco surgery question bank based on MD Anderson Surgical Oncology Handbook 6th edition and NCCN guidelines should be on the wish list of every resident aspiring to be an hot shot onco-surgeon. The GI surgery package is about to be released soon. There are also extensive video lectures on GI surgery which would be an invaluable resource on GI surgery for residents. Residents can contact the team for discounts. 


I have covered a few aspects of studying during residency. In future chapters, I will cover research during residency, negotiations seniors and diplomacy while a resident and a few other topics. Since it is an extensive topic, I have not covered MRCS preparation. MRCS preparation is definitely possible even while you are a resident and I am gonna tell you how to crack both parts of MRCS even before you finish MS/DNB.

There is nothing more satisfying than treating the patient the right way. The patient puts his/her full trust on you. It is extremely essential that we understand this. It is a huge privilege to be a surgeon. That privilege comes with a huge responsibility. One major aspect of that responsibility is acquiring knowledge.

Learn well. Treat well.

Vinayak Rengan is a General surgeon from Chennai who completed his Surgical residency at Madras Medical College. He is a compulsive news junkie who regularly writes for print media and runs a blog The Stonebench where he writes on technology, public health and politics . He is the co-founder of Surgtest - a surgical education platform which helps surgeons prepare for NEET SS and MRCS.

#neetss #surgery #residency #indiaPG #Generalsurgery

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There are about 3000 young minds entering surgery residency in India this year. Most of them have waited for months and years to be a surgeon. During their internship as they assisted their PGs in a hernia and while suturing broken foreheads - all they wanted to be was “a surgeon”. It indeed is a proud moment for them and their families, I want to start by congratulating them for their phenomenal achievement. 

However the path ahead is fraught with challenges and struggles. Surgery residency in India is one of the toughest and most brutal periods of a medical student's life. Some residents have a good life where they are treated with dignity. Others are treated as lowly slaves and drivers. You might learn a lot under a fantastic teacher or you might not be allowed to operate even a hernia all your residency. In the short term, these are extremely important. However in the longer run, these factors does not matter at all. One of the first things you must remember is that training doesn’t not end with residency. There is an option of doing senior residency is top institutes after your surgery residency where you will get exposed to best practices in the field. So never despair. One of the finest GI surgeons I know was allowed to operate on only 2 appendectomies throughout his residency. This did not stop him from being a maestro in GI surgery. One of the finest laparoscopic hernioplasties I have ever seen was performed by a surgeon who did his DNB in a corporate hospital well known in surgical circles for not allowing residents to even scrub up for cases. However both these surgeons had one thing in common: an intense desire to succeed. 

How to be a good resident?

One of the most important qualities you need is compassion. Good residents are usually the most compassionate people you can ever meet. They work hard because they know that the effort they put translates into quality care for their patients.

A good resident also is a knowledgable resident. When you work in a high volume centre, you will be expected to take decisions that impact your patient’s care. Good decisions can be made only if the resident is reasonably knowledgable. 

Residency involves a lot of effort and stamina. Investing in your health is extremely important. There are hardworking residents who tend to fall sick often. They miss out on learning and operating chance simply because their health doesn’t permit them. 

Diplomacy is one of the most important aspects of residency. Indian surgery training is brutally hierarchical and negotiating through the complex maze of surgical heirarchy is not a simple task. 

We shall analyse each parameter in detail.


It is a very tough task to be polite when there are 300 patients waiting in the OPD, especially when you haven’t slept for the past 36 hours. The surgical training programs in high volume centres are designed to be efficient, not patient friendly. However it is essential that you maintain your goodness and compassion even during residency. There will always be that one resident who doesn’t shout at patients and juniors. Invariably he/she is the one who evinces maximum respect from staff and doctors. That resident should be your example. 

There are good selfish reasons to be compassionate. A small smile at the boy who pushes the stretcher goes a long way. When I was a resident at Madras Medical College not long ago, I would ensure that the OT boys had food before dinner time ends. I would also make sure that I learnt the names of every staff and worker who worked with me. Addressing everyone by their names shows that you respect them and have made the effort to learn their names. These small gestures go a long way. The OT boys would make sure that my case was wheeled in even before the brutes from orthopaedics rushed in to occupy the lone table in the emergency OT. On a particular summer post admission day morning when I almost collapsed due to dehydration, one of the senior staff nurses fed me with her own hands. These are moments which shall remain etched in my memory for long. 

Compassion towards your patients is a must even before you enter residnecy. If you feel, you dont give a damn about your patients - surgery is not the place to be. Treat your patients as human beings, not as operating opportunities. If you feel that a T4 lesion in the breast needs chemotherapy before surgery, dont push for surgery just because it is your chance. If a patient with rectal CA needs neoadjuvant RT before surgery, it is important that you ensure that the right treatment is ensured. 

Be an advocate for your patients. Fight alongside them for their rights. Most of the patients in government hospitals have come here because they have nowhere else to go. It is matter of huge privilege that you are given the opportunity to treat them. For you it might be just an emergency splenectomy. For the mother, it is her 24 year old son who has had a major accident and is battling for his life with a shattered spleen. A patient is not just a case. When a patient or an attender has a query, take time to explain to them the situation. If you dont have the time, apologise and promise them that your intern will answer the query or you will come back later. Do remember to keep your promise. It is quite easy for me to type these things but your small gesture will be remembered for a long time. 

At the end of the day, be the resident you want to be treated by.

In the next part, I will discuss on strategies to study during residency. 

Recommended reading material about surgery residency

These 2 books about a surgery resident’s life also talk about the human aspects of residency. A lot of young Indian residents  will able to relate to Heart,Guts & Steel which is about residency in a Bombay Hospital by the ever brilliant Dr Sivasubramanian. 

Vinayak Rengan is a General surgeon from Chennai who completed his Surgical residency at Madras Medical College. He is a compulsive news junkie who regularly writes for print media and runs a blog The Stonebench where he writes on technology, public health and politics . He is the co-founder of Surgtest - a surgical education platform which helps surgeons prepare for NEET SS and MRCS.

#neetss #surgery #residency #indiaPG #Generalsurgery

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Case History

A 22 year old female presented with complaints of abdominal pain, abdominal distension, nausea, vomiting and anorexia. On examination the abdomen was distended with diffuse tenderness. But there was no guarding, rigidity or rebound tenderness.

Abdomino-pelvic CT scan was suggestive of Intestinal obstruction and Abdominal Tuberculosis. It revealed  distended bowel loops, large amounts of ascites, symmetrical thickening of the peritoneum and mesentery, nodular thickening of greater omentum and mesenteric lymphadenopathy.

After conservative management for first 24 hours, patient showed no signs of improvement. An exploratory laparotomy was planned. Intraoperatively it was found that Multiple Adhesions between bowel loops and an omental band were causing the obstruction. Adhesiolysis was done and thorough wash was given. Omentum, peritoneum, bowel wall, uterus and adnexa were all seen studded with tubercles. Omentum was thickened and nodular, a piece of it was taken and sent for HPE. Ascitic fluid was blood stained and a sample was taken for biochemical analysis.

Postoperatively patient's condition improved and she passed flatus on 3rd POD and passed stools on 5th POD.  Patient was started on antitubercular drugs and was discharged on 8th POD.

Abdominal tuberculosis showing thickened bowel loops studded with tubercles

Abdominal tuberculosis showing thickened bowel loops  studded with tubercles

Tuberculous peritonitis: Important Points to remember 

Peritoneal tuberculosis is the sixth most common site of extrapulmonary tuberculosis. The top five are lymphatic, genitourinary, bone and joint, miliary, and meningeal. 

Only 17% of cases of peritoneal tuberculosis are associated with active pulmonary disease.  

Abdominal swelling caused by ascites formation is the most common symptom, occurring in more than 80% of cases. 

A positive tuberculin skin test response is present in most cases. But only approximately 50% of these patients will have an abnormal chest radiograph.

Abdominal imaging with ultrasound or CT may suggest the diagnosis but lacks the sensitivity and specificity to be diagnostic.

Ascitic fluid adenosine deaminase activity, in particular, appears to be highly sensitive and specific for tuberculous peritonitis.

The ascitic fluid SAAG is less than 1.1 g/dL, indicating high protein concentration in the ascitic fluid

Microscopic examination of ascitic fluid for acid-fast bacilli identifies the organism in less than 3% of cases, and culture results are positive in less than 20% of cases.


Laparoscopic Cholecystectomy Steps

  1. Prepare the patient
  2. Placement of first 10mm trocar (midline navel)
Below is a video showing the gross anatomy of liver. Also you will find two nice presentations covering gross and segmental anatomy of liver in depth. Questions related to the segmental anatomy of liver are very commonly asked in examinations.

This presentation explains segmental anatomy of liver very well.

All about Surgical Anatomy of Liver.

Check out these related videos:

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Laparoscopic Appendectomy Steps

Step 1: Port placement: A 10-mm trocar is placed at the umbilicus, and the abdominal cavity is insufflated to a pressure of 15 mmHg. The camera is also inserted through this larger trocar.

A 5-mm trocar is placed at the suprapubis, and a second 5-mm trocar is placed at the LLQ.

Step 2: Inspect abdominal cavity: The area is inspected to orient the surgeon to the position of the appendix.

Step 3: Expose appendix: The bowel is gently retracted rostrally using atraumatic graspers to allow access to appendix.

Step 4: Locate and separate appendicular artery: The mesoappendix is separated from the body of the appendix, and the mesenteric fat is separated to reveal the appendicular artery. This is best done using the “spreader” action of a dissector.

Step 5: Divide appendix from cecum: Using an endoloop, two loops are placed proximal to the cecum, and a third loop is placed 1-2 cm distally to these. The appendix is then divided between the two proximal and 3rd distal loops using scissors or cautery.

Step 6: Extract appendix: The camera may be withdrawn and the existing 10 mm port used for extraction

Step 8: Irrigate: The abdominal cavity should be irrigated thoroughly with sterile saline and suctioned clean several times. In the event of a rupture, great care should be taken to ensure all pus or other infectious fluids have been removed.

Step 9: Final inspection: The abdominal and pelvic cavities are inspected one final time for any signs of infection, errors, or other potential complications.

Check out these related videos:

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Milestones in the history of intestinal anastomosis

Intestinal anastomosis has been successfully performed for more than 150 years using a variety of techniques and suture materials. Major milestones in the development of this technique are:

Lembert : Seromuscular suture technique for bowel anastomosis in 1826

Kocher : Utilised a two-layer anastomosis. First a continuous all-layer suture using catgut, then an
inverting continuous (or interrupted) seromuscular layer suture using silk

Halsted : Favoured a one layer extramucosal closure, it was felt to cause the least tissue necrosis or
luminal narrowing. This technique has now become widely accepted.

Currently accepted technique for intestinal anastomosis

Of these, the method that has proven successful in most situations and in the hands of most surgeons has been the two-layer anastomosis using interrupted silk sutures for an outer inverted seromuscular layer and a running absorbable suture for a transmural inner layer.

The only appreciable shortcoming of the two-layer technique is that it is somewhat tedious and time-consuming to perform. Recently, several reports have appeared advocating a single-layer continuous anastomosis using monofilament plastic suture.

Single layer continuous extramucosal closure has now become widely accepted.

A single-layer continuous anastomosis can be constructed in significantly less time and with a similar rate of complications compared with the two-layer technique. It also costs less than any other method and can be incorporated into a surgical training program without a significant increase in complications.

Single Layer , Extramucosal, Interrupted- End to End bowel anastomosis (simulation)

Side to side bowel anastomosis (simulated)

Difference between Extramucosal Technique and Seromuscular Suture Technique

The extramucosal suture must include the submucosa as this has a high collagen content and is the most stable suture layer in all sections of the gastrointestinal tract.

Suture Materials used in Intestinal Anastomosis

Catgut and silk have been replaced by synthetic, usually absorbable, polymers.

The suture materials should be of 2/0–3/0 size and made of an absorbable polymer, which can be braided (e.g. polyglactin), or monofilament (e.g. polydioxanone), mounted on an atraumatic round-bodied needle. 

Suture bites should be approximately 3–5 mm deep and 3–5 mm apart depending on the thickness of
the bowel wall.

Stay sutures are put to avoid the need for tissue forceps. They are important for displaying the bowel
ends and in accurate alignment of the bowel and the placement of the sutures.

Important Considerations while doing Bowel Anastomosis

In cases of major size discrepancy of size of bowel end to be anastamosed, a side-to-side or end-to-side anastomosis is done.

In cases of minor size discrepancy, Cheatle split (making a cut into the antimesenteric border) may
help to enlarge the lumen of distal, collapsed bowel and allow an end-to-end anastomosis to be fashioned.

Introducing surgery MCQs in cram sheet format to get the most out of your limited time online. Will be adding more MCQs patterned for NEET SS, DNB CET SS and MRCS Part A exams.

S.NOQuestionAnswer and Explanation
1.Liver abscess ruptures most commonly in
a. Pleural cavity
b. Peritoneal cavity
c. Pericardial cavity
d. Bronchus

b. Peritoneal cavity
High risk of rupture
· size >5 cm
· left lobe abscess

2.True about amoebic liver abscess:
a. Male: female >10:1
b. Not predisposed by alcohol
c. More common in diabetics
d. E. histolytica is isolated in >50% from blood culture

a. Male: female >10:1
Majority of patients are young men (may be due to heavy alcohol consumption)
3.Not an indication for percutaneous aspiration in amoebic liver abscess)
a. Radiographically unresolved lesion afer 6 months
b. Suspected diagnosis
c. Lef lobe liver abscess
d. Compression or outflow obstruction of hepatic or portal vein

a. Radiographically unresolved lesion afer 6 months
Radiologic resolution of the abscess cavity is usually delayed. The average time to radiologic resolution is 3 to 9 months and can take as long as years in some patients. Clinical improvement after adequate treatment with antiamoebic agents is a rule.
4.Liver biopsy is done through 8th ICS midaxillary line to avoid:
a. Lung
b. Pleural cavity
c. Subdiaphragmatic space
d. Gall bladder

a. Lung
Liver biopsy is done through 8th ICS in midaxillary line to avoid Lung
5.“Crumbled egg appearance” in liver is seen in
a. Hepatic adenoma
b. Chronic amoebic liver abscess
c. Hydatid liver disease
d. Hemangioma

c. Hydatid liver disease
Crumbled egg appearance in liver is seen in hydatid disease

6.Honey-comb liver is seen in
a. Micronodular cirrhosis
b. Dubin Johnson’s syndrome
c. Actinomycosis
d. Hydatidosis

c. Actinomycosis
Most commonly, Actinomyces reaches liver through portal vein. Liver is gradually replaced by multiple abscesses, typical honey comb liver
7.Primary sinusoidal dilatation of liver is also known as:
a. Hepar lobatum
b. Peliosis hepatis
c. Von-Meyerburg complex
d. Caroli’s disease

b. Peliosis hepatis
It is an uncommon disorder characterized by multiple, small, blood-filled sinuses. It occurs in immunocompromised postransplant patients, AIDS patients, and patients taking long term steroids.
8.Not a contraindication of lap cholecystectomy:
a. Acute Cholecystitis
b. Ca Gallbladder
c. Portal Hypertension
d. Bleeding Diathesis

a. Acute Cholecystitis
In Acute cholecystitis, Lap cholecystectomy IS NOT CONTRAINDICATED. In other conditions surgery should be done by open method.
9.A patient presented with RIF pain with dyspepsia. USG showed edematous GB wall. What will be the most sensitive investigation to confirm the suspected diagnosis?
b. MRI

Hydroxy-iminodiacetic acid (HIDA) is taken by liver and excreted into bile. Failure to fill gallbladder in a time of 2 hours is indicative of Acute cholecystitis
10.True statement regarding choledochal cyst is all except:
a. Type 2 is most common
b. Type 1 needs excision and biliary anastomosis
c. Surgical excision is the treatment of choice
d. Associated with anomalous union of pancreatic and bile duct

a. Type 2 is most common

As per Todani classification of Choledocal cysts:
· Most common choledochal cyst – Type 1
· APBDJ is seen in 90% of choledochal cyst cases


  • Autosomal dominant polycystic kidney disease (ADPKD) is one of the most common hereditary renal disorders characterized by varied manifestations including renal cysts, extrarenal cysts, intracranial aneurysms and dolichoectasias, aortic root dilatation and aneurysms, mitral valve prolapse, and abdominal wall hernias
  • Approximately one per 800-1000 population carries a mutation for this condition.
  • There is established association between ADPKD patients with ESRD and Renal cell carcinoma
  • The association of liver, colon and renal cancer with polycystic kidney disease without end-stage renal disease has also been reported
  • But only a few cases of gastric carcinoma happening in ADPKD patients have been reported.

Clinical Presentation

  • The patient was a 55-year- old male whose chief complaints were abdominal pain, vomiting, jaundice and weight loss. 
  • He was a known case of Autosomal dominant polycystic kidney disease. 
  • His father also had Kidney problems  and elder brother also is a k/c/o ADPKD. 


  • Abdominal imaging studies showed bilateral polycystic kidneys, an irregular asymmetrical circumferential wall thickening of pylorus for a length of 5.6 cm with obstruction of the proximal bile duct and dilated intrahepatic biliary radicles.

Intraoperative Findings

  • A mass arising from pylorus was seen infiltrating into the lesser omentum along with involvement of porta hepatis lymph node with fibrosis and stricture at the confluence of hepatic ducts. 
  • However no compression or involvement of distal CBD was observed. 
  • Hence, the malignant stricture and fibrosis at the hepatic duct confluence was inferred as the cause for obstructive jaundice

Surgical Management

  • Roux en y hepaticojejunostomy, Subtotal gastrectomy, gastrojejunostomy, cholecystectomy and jejunojunostomy were done.

Histopathological Report

  • HPE revealed a well differentiated adenocarcinoma of the stomach. The duodenal stump and resected margins were free of tumour. Samples of fibrotic tissue from the site of obstruction at the confluence of hepatic ducts were negative for tumour infiltration as well.

Postoperative Period

  • Patient recovered uneventfully from surgery and the serum bilirubin reduced after which he was referred to medical oncology for chemotherapy.

ADPKD and Adenocarcinoma of Stomach

  • 4 cases of Carcinoma stomach were found in literature review which were reported in association with ADPKD. 
  • One of the case reports reported siblings with ADPKD, both developing adenocarcinoma of stomach.

Torres VE, Harris PC, Pirson Y (2007). "Autosomal dominant polycystic kidney disease.". Lancet. 369 (9569): 1287–1301. doi:10.1016/S0140-6736(07)60601-1. PMID 17434405
Dalgaard OZ (1957). "Bilateral polycystic disease of the kidneys; a follow-up of two hundred and eighty-four patients and their families". Acta Med. Scand. Suppl. 328: 1–255. PMID 13469269
Torres, Vicente; Harris, Peter C (2009). "Autosomal dominant polycystic kidney disease: the last 3 years“
Risk of cancer in patients with polycystic kidney disease: a propensity-score matched analysis of a nationwide, population-based cohort study: Yu, Tung-Min et al. The Lancet Oncology , Volume 17 , Issue 10 , 1419 – 1425
Halvorson CR, Bremmer MS, Jacobs SC. Polycystic kidney disease: inheritance, pathophysiology, prognosis, and treatment. International Journal of Nephrology and Renovascular Disease. 2010;3:69-83.
Two Cases of Gastric Carcinoma with Autosomal Dominant Polycystic Kidney Disease in the Same Family: KAYA, AKDAĞ, COŞKUNOĞLU, TÜRKELİ, YILMAZ. Turkiye Klinikleri J Med Sci 2012;32(6):1796-800
Carcinoma of the gastroesophageal junction associated with adult polycystic kidney disease: Aziz SA, Ahmad M, Shah A. Nephron. 1998;79(3):362-3.  PMID: 9678447