mkdir -p /home/daytona/workspace/surgery-pptx && ls /home/daytona/workspace/surg…

~/surgery-pptx/build.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE";
pres.title = "Large Intestine: Surgery Presentation";
pres.author = "Surgery Department";

// ─── THEME ───────────────────────────────────────────────────────────────────
const C = {
  navy:    "0D2137",
  teal:    "1A6B72",
  gold:    "E8A020",
  white:   "FFFFFF",
  offWhite:"F4F6F8",
  light:   "D6E4EA",
  dark:    "0A1929",
  accent:  "2EC4B6",
  red:     "C0392B",
  text:    "1C2D3A",
  sub:     "3A5068",
};

const FF = "Calibri";

// ─── HELPERS ─────────────────────────────────────────────────────────────────
function addBg(slide, dark = false) {
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function addSideBar(slide, color = C.teal) {
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function addTopBar(slide, color = C.teal, h = 1.1) {
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}

function sectionHeader(title, subtitle = "") {
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    valign: "middle",
  });
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      fontFace: FF, fontSize: 22, color: C.light, italic: true,
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  }
  return s;
}

function contentSlide(title, columns) {
  // columns: array of { heading, bullets }
  const s = pres.addSlide();
  addBg(s, false);
  addTopBar(s, C.teal, 1.05);
  addSideBar(s, C.navy);

  s.addText(title, {
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    fontFace: FF, fontSize: 26, bold: true, color: C.white,
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  const colH = 5.9;

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      valign: "top", wrap: true, margin: [4, 4, 4, 4],
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  return s;
}

// ═══════════════════════════════════════════════════════════════════════════════
//  TITLE SLIDE
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  // gradient-ish navy bg
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.dark }, line: { type: "none" } });
  // decorative teal rectangle
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  s.addShape(pres.ShapeType.rect, { x: 1.5, y: 5.1, w: 10.3, h: 0.1, fill: { color: C.gold }, line: { type: "none" } });

  s.addText("LARGE INTESTINE", {
    x: 0, y: 0.9, w: "100%", h: 0.85,
    fontFace: FF, fontSize: 18, bold: false, color: C.accent,
    align: "center", charSpacing: 8,
  });
  s.addText("Surgery Presentation", {
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    fontFace: FF, fontSize: 46, bold: true, color: C.white,
    align: "center",
  });
  s.addText("Clinical Features  ·  Surgical Treatment  ·  Management", {
    x: 0, y: 3.0, w: "100%", h: 0.7,
    fontFace: FF, fontSize: 17, color: C.light,
    align: "center", italic: true,
  });

  const topics = [
    "Adenomatous Polyps", "Familial Adenomatous Polyposis", "Lynch Syndrome",
    "Colorectal Cancer", "Inflammatory Bowel Disease", "Infections of Large Intestine",
    "Vascular Anomalies", "Constipation", "Irritable Bowel Syndrome"
  ];
  const topicText = topics.map((t, i) => ({
    text: (i < topics.length - 1 ? t + "   ·   " : t),
    options: { fontSize: 12, color: C.light, fontFace: FF }
  }));
  s.addText(topicText, {
    x: 0.5, y: 4.0, w: 12.3, h: 1.2,
    align: "center", valign: "middle", wrap: true,
  });
  s.addText("Bailey & Love · Mulholland & Greenfield · Schwartz's Surgery · Rosen's EM", {
    x: 0, y: 6.55, w: "100%", h: 0.35,
    fontFace: FF, fontSize: 10, color: C.teal, align: "center",
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
//  1. ADENOMATOUS POLYPS
// ═══════════════════════════════════════════════════════════════════════════════
sectionHeader("1. Adenomatous Polyps", "Neoplastic epithelial lesions — precancerous precursors to CRC");

contentSlide("Adenomatous Polyps — Overview & Clinical Features", [
  {
    heading: "Definition & Types",
    bullets: [
      "Epithelial lesions — smooth to nodular as they grow",
      "Tubular adenoma: ≥80% dysplastic tubules (most common, 80%)",
      "Villous adenoma: ≥80% villous fronds (highest malignant risk)",
      "Tubulovillous adenoma: mixed features",
      "By definition dysplastic — nuclear atypia & architectural irregularity",
      "Found in up to 50% of screening colonoscopies",
      "Prevalence increases with age; incidence rising globally",
      "2–3× CRC risk with first-degree relative with adenomas",
    ],
  },
  {
    heading: "Clinical Features",
    bullets: [
      "Usually asymptomatic — found incidentally on colonoscopy",
      "Rectal bleeding (hematochezia) — most common symptom",
      "Change in bowel habits — constipation or diarrhea",
      "Large villous adenomas → profuse watery diarrhea, hypokalemia",
      "Abdominal cramping or discomfort (larger polyps)",
      "Mucus per rectum with villous adenomas",
      "Iron-deficiency anemia from chronic occult blood loss",
      "Rarely palpable on digital rectal examination (rectal polyps)",
    ],
  },
  {
    heading: "Diagnosis & Risk Stratification",
    bullets: [
      "Colonoscopy: gold standard — visualization + biopsy",
      "CT colonography (virtual colonoscopy) if colonoscopy contraindicated",
      "Fecal occult blood test (FOBT) / fecal immunochemical test (FIT)",
      "High-risk features: size >1 cm, villous histology, high-grade dysplasia",
      "Advanced adenoma: ≥1 cm OR villous OR high-grade dysplasia",
      "Adenoma-carcinoma sequence: APC → K-ras → p53 mutations",
      "30–50% chance of additional synchronous adenoma",
      "Surveillance interval based on number, size, and histology",
    ],
  },
]);

contentSlide("Adenomatous Polyps — Treatment & Management", [
  {
    heading: "Endoscopic Treatment",
    bullets: [
      "Polypectomy: standard snare excision for pedunculated polyps",
      "Endoscopic mucosal resection (EMR) for sessile polyps ≤2 cm",
      "Endoscopic submucosal dissection (ESD) for larger sessile lesions",
      "Piecemeal resection for polyps >2 cm if ESD not available",
      "Tattooing polyp site for surgical planning if needed",
      "Complete excision confirmed by histology (clear margins)",
      "Cold snare preferred for polyps <10 mm (lower perforation risk)",
    ],
  },
  {
    heading: "Surgical Treatment",
    bullets: [
      "Indicated for: polyps not amenable to endoscopic removal",
      "Polyps with high-grade dysplasia / intramucosal carcinoma",
      "Failed endoscopic resection or incomplete excision",
      "Laparoscopic colectomy — preferred (faster recovery, cosmesis)",
      "Open colectomy — for complex cases or locally advanced disease",
      "Segmental resection based on blood supply and lymphatics",
      "Right hemicolectomy (cecum/ascending colon polyps)",
      "Sigmoid colectomy / anterior resection for left-sided polyps",
    ],
  },
  {
    heading: "Surveillance & Management",
    bullets: [
      "Low-risk (1–2 small tubular adenomas): colonoscopy at 5–10 years",
      "High-risk (3–4 adenomas, or advanced adenoma): at 3 years",
      "≥5 adenomas: colonoscopy at 1 year",
      "Post-polypectomy: confirm complete excision histologically",
      "Chemoprevention: Aspirin/NSAIDs reduce recurrence (not routine)",
      "Lifestyle: diet high in fibre, low in red/processed meat",
      "Genetic counseling if strong family history",
      "Annual FOBT in higher-risk populations",
    ],
  },
]);

// ═══════════════════════════════════════════════════════════════════════════════
//  2. FAMILIAL ADENOMATOUS POLYPOSIS
// ═══════════════════════════════════════════════════════════════════════════════
sectionHeader("2. Familial Adenomatous Polyposis (FAP)", "Autosomal dominant — APC gene mutation — 100% lifetime CRC risk");

contentSlide("FAP — Definition, Genetics & Clinical Features", [
  {
    heading: "Genetics & Pathology",
    bullets: [
      "Mutation in APC gene (chromosome 5q21) — autosomal dominant",
      "Classic FAP: >100 colorectal adenomas (often thousands)",
      "Attenuated FAP (AFAP): <100 polyps; later onset (4th decade)",
      ">80% have positive family history; ~20% are new mutations",
      "Lifetime CRC risk: virtually 100% without prophylactic surgery",
      "Codon 1309 mutation → most severe phenotype",
      "Codons 1286–1513 → worse prognosis, earlier disease onset",
      "Gardner's syndrome: FAP + osteomas + epidermoid cysts",
    ],
  },
  {
    heading: "Clinical Features",
    bullets: [
      "Polyps visible on sigmoidoscopy by age 15; always by age 30",
      "Rectal bleeding, change in bowel habit, mucus PR",
      "Abdominal pain; iron-deficiency anemia",
      "Duodenal adenomas (periampullary) — risk of duodenal cancer",
      "Desmoid tumours (mesentery) — locally invasive, non-metastatic",
      "Osteomas (jaw, skull, long bones)",
      "CHRPE (congenital hypertrophy of retinal pigment epithelium) — 50%",
      "Epidermoid cysts, brain tumours (Turcot's syndrome)",
    ],
  },
  {
    heading: "Screening & Diagnosis",
    bullets: [
      "Flexible sigmoidoscopy from age 12–14 years in at-risk family members",
      "Colonoscopy once polyps detected",
      "Genetic testing: APC gene mutation analysis",
      "Upper GI endoscopy: screen for duodenal/ampullary adenomas",
      "Spigelman classification for duodenal polyposis severity",
      "If >100 adenomas on colonoscopy → diagnosis confirmed",
      "AFAP: colonoscopy (not just sigmoidoscopy) required",
      "Family tree construction; refer to medical genetics",
    ],
  },
]);

contentSlide("FAP — Surgical Treatment & Postoperative Management", [
  {
    heading: "Surgical Options",
    bullets: [
      "Goal: prevent colorectal cancer — prophylactic surgery mandatory",
      "Surgery usually deferred to age 17–18 unless symptoms develop",
      "Malignant change unusual before age 20",
      "Option 1: Restorative proctocolectomy + ileal pouch-anal anastomosis (IPAA) — removes entire colorectum, avoids stoma",
      "Option 2: Total colectomy + ileorectal anastomosis (IRA) — for <20 rectal polyps; preserves rectum",
      "Option 3: Total proctocolectomy + end ileostomy — poor sphincter function, rectal cancer, single-stage preference",
      "Laparoscopic approach: faster recovery, better cosmesis, improved fecundity in women",
    ],
  },
  {
    heading: "IPAA vs IRA Considerations",
    bullets: [
      "IPAA: preferred for most — removes all at-risk colorectal mucosa",
      "IPAA failure rate ~10%; pouch surveillance still needed",
      "Stapled anastomosis → residual rectal cuff mucosectomy advocated",
      "IRA: suitable if <20 rectal polyps; lower sexual/fertility dysfunction risk",
      "IRA: up to 10% develop rectal cancer — mandatory rectal surveillance",
      "AFAP: rectal-preserving surgery acceptable (cancer risk ~2%)",
      "Proctocolectomy + ileostomy: definitive, no surveillance required",
    ],
  },
  {
    heading: "Postoperative & Medical Management",
    bullets: [
      "IPAA/IRA: lifelong endoscopic surveillance of pouch/rectum",
      "Duodenal surveillance: upper GI endoscopy every 1–5 years (Spigelman stage)",
      "Spigelman stage IV → consider prophylactic pancreaticoduodenectomy",
      "Sulindac (NSAID): reduces polyp number in rectum post-IRA",
      "Celecoxib: reduces duodenal/rectal polyp burden",
      "Desmoid tumours: sulindac, tamoxifen, chemotherapy (doxorubicin/dacarbazine) if unresectable",
      "Register patients with national FAP registry",
      "Annual thyroid exam; consider hepatoblastoma screening in children",
    ],
  },
]);

// ═══════════════════════════════════════════════════════════════════════════════
//  3. LYNCH SYNDROME
// ═══════════════════════════════════════════════════════════════════════════════
sectionHeader("3. Lynch Syndrome (HNPCC)", "Most common hereditary CRC syndrome — mismatch repair gene defects");

contentSlide("Lynch Syndrome — Genetics & Clinical Features", [
  {
    heading: "Genetics & Epidemiology",
    bullets: [
      "Autosomal dominant — mismatch repair (MMR) gene mutations",
      "Genes: MLH1, MSH2, MSH6, PMS2, EpCAM",
      "3–5% of all colorectal cancers (1 in 20)",
      "Lifetime CRC risk: 53–69%; median age diagnosis: early 60s",
      "MLH1 mutation → younger age of onset vs MSH2, PMS2",
      "PMS2 mutations: relatively lower CRC risk",
      "Amsterdam II criteria used for clinical diagnosis",
      "Microsatellite instability (MSI-H) hallmark on tumour testing",
    ],
  },
  {
    heading: "Clinical Features",
    bullets: [
      "Fewer adenomas than FAP (<10 polyps, usually)",
      "Right-sided colonic predominance — flat adenomas",
      "Rapid progression from adenoma to dysplasia to cancer",
      "High rate of metachronous colorectal tumours (3–5% annual)",
      "Rectal bleeding, change in bowel habits, abdominal pain",
      "Associated extra-colonic cancers: endometrial (most common), ovarian, gastric, small bowel, urinary tract, biliary tract",
      "Sebaceous skin tumours (Muir-Torre syndrome variant)",
      "Brain tumours (glioblastoma) — Turcot's syndrome variant",
    ],
  },
  {
    heading: "Diagnosis",
    bullets: [
      "Amsterdam II Criteria: 3 relatives with Lynch-associated cancer, 2+ generations, 1 case <50 years old, FAP excluded",
      "Revised Bethesda Guidelines: clinical screening trigger",
      "Tumour testing: MSI testing + immunohistochemistry (IHC) for MMR proteins",
      "Loss of MLH1/PMS2 or MSH2/MSH6 on IHC → germline testing",
      "Germline genetic testing: confirms specific mutation",
      "Universal tumour screening: all CRC specimens tested for MMR status",
      "Mutation-specific cancer risks guide surveillance intensity",
    ],
  },
]);

contentSlide("Lynch Syndrome — Treatment & Management", [
  {
    heading: "Surgical Treatment of CRC in Lynch",
    bullets: [
      "Extended colonic resection preferred over segmental (high metachronous risk)",
      "Subtotal colectomy + ileorectal anastomosis: for colon cancer",
      "Reduces metachronous CRC risk vs. segmental resection",
      "Total proctocolectomy: if rectal cancer or significant rectal disease",
      "Annual surveillance colonoscopy (vs. 3-yearly in sporadic CRC)",
      "Laparoscopic approach: standard in experienced hands",
      "Synchronous liver metastases: resect if feasible",
    ],
  },
  {
    heading: "Gynaecological Management",
    bullets: [
      "Endometrial cancer risk: 40–60% (most common extra-colonic cancer)",
      "Prophylactic hysterectomy + bilateral salpingo-oophorectomy: after childbearing complete",
      "Annual gynaecological surveillance: endometrial biopsy, transvaginal USS",
      "Ovarian cancer risk: 10–12%",
      "Discuss risk-reduction surgery with gynaecologist",
      "Oral contraceptive use: may reduce gynaecological cancer risk",
    ],
  },
  {
    heading: "Surveillance & Medical Management",
    bullets: [
      "Colonoscopy every 1–2 years from age 25 (or 5 years before earliest family case)",
      "Upper GI endoscopy: for gastric/small bowel surveillance in high-risk families",
      "Annual urinalysis (urothelial cancer surveillance)",
      "Aspirin 600 mg/day: proven CRC reduction in Lynch (CAPP2 trial)",
      "Immunotherapy (pembrolizumab): highly effective for MMR-deficient advanced CRC",
      "Cascade genetic testing: all first-degree relatives",
      "Psychosocial support and genetic counseling",
    ],
  },
]);

// ═══════════════════════════════════════════════════════════════════════════════
//  4. COLORECTAL CANCER
// ═══════════════════════════════════════════════════════════════════════════════
sectionHeader("4. Colorectal Cancer (CRC)", "2nd most common cancer death in the UK · ~42,000 new UK cases/year");

contentSlide("Colorectal Cancer — Epidemiology & Clinical Features", [
  {
    heading: "Epidemiology & Pathology",
    bullets: [
      "2nd most common cause of cancer death in the UK",
      "~42,000 new cases/year UK; male > female (56% vs 44%)",
      "Rectum 38%, sigmoid 21%, caecum 12%, ascending colon 5%",
      "Adenoma-carcinoma sequence: APC → K-ras → SMAD4 → p53",
      "Four consensus molecular subtypes (CMS1–4)",
      "MSI-H tumours: right-sided, better prognosis, immunotherapy-sensitive",
      "Risk factors: red/processed meat, alcohol, smoking, obesity",
      "Protective: dietary fibre, calcium, magnesium, aspirin",
    ],
  },
  {
    heading: "Clinical Features",
    bullets: [
      "Right colon: insidious blood loss → iron-deficiency anaemia, weight loss, RIF mass",
      "Left colon: change in bowel habit, rectal bleeding, tenesmus, pencil-thin stools",
      "Rectal cancer: rectal bleeding, tenesmus, incomplete evacuation, rectal mass on DRE",
      "Obstruction: colicky abdominal pain, absolute constipation, distension",
      "Perforation: peritonitis, septic shock (emergency presentation)",
      "Fistula formation to bladder (pneumaturia), vagina, skin",
      "Liver metastases: hepatomegaly, jaundice, RUQ pain",
      "Constitutional: weight loss, anorexia, fatigue",
    ],
  },
  {
    heading: "Staging (Dukes / TNM)",
    bullets: [
      "Dukes A: confined to bowel wall (T1–2, N0)",
      "Dukes B: through bowel wall, no nodes (T3–4, N0)",
      "Dukes C: regional lymph node involvement (any T, N1–2)",
      "Dukes D: distant metastases (M1)",
      "TNM: T (depth), N (nodes 0/1/2), M (metastases 0/1)",
      "CT chest/abdomen/pelvis: staging workup",
      "MRI rectum: T staging, CRM assessment for rectal cancer",
      "CEA: baseline (prognostic) + post-operative surveillance",
    ],
  },
]);

contentSlide("Colorectal Cancer — Surgical Treatment", [
  {
    heading: "Colon Cancer Surgery",
    bullets: [
      "Curative intent: radical resection with clear margins (R0)",
      "Right hemicolectomy: caecum, ascending, hepatic flexure tumours",
      "Extended right hemicolectomy: transverse colon tumours",
      "Left hemicolectomy: descending colon tumours",
      "Sigmoid colectomy: sigmoid colon tumours",
      "Principle: en-bloc resection with supplying mesentery + lymph nodes",
      "Minimum 12 lymph nodes for adequate staging",
      "Laparoscopic colectomy: equivalent oncological outcomes, faster recovery",
      "Robotic surgery: emerging, improved dexterity in pelvis",
    ],
  },
  {
    heading: "Rectal Cancer Surgery",
    bullets: [
      "Total mesorectal excision (TME): gold standard for rectal cancer",
      "Sharp dissection in mesorectal plane preserves autonomic nerves",
      "Anterior resection (AR): for upper/mid rectum — colorectal/coloanal anastomosis",
      "Low anterior resection (LAR): temporary defunctioning stoma common",
      "Abdominoperineal resection (APR): for very low tumours — permanent colostomy",
      "Hartmann's procedure: left-sided obstruction/perforation",
      "Transanal TME (TaTME): improved access for obese/narrow pelvis patients",
      "HIPEC: for peritoneal metastases (selected centres)",
    ],
  },
  {
    heading: "Multimodal & Palliative Management",
    bullets: [
      "Neoadjuvant chemoradiotherapy (long course) or short-course RT: rectal cancer (downsizing)",
      "Adjuvant chemotherapy: FOLFOX/CAPOX for stage III (and high-risk II)",
      "Biologic agents: bevacizumab (anti-VEGF), cetuximab/panitumumab (RAS wild-type)",
      "Immunotherapy: pembrolizumab for MSI-H/dMMR tumours",
      "Colorectal stenting: bridge to surgery in obstructing CRC",
      "Liver resection: for resectable hepatic metastases (30–40% 5-year survival)",
      "MDT: mandatory preoperative + postoperative discussion",
      "5-year survival: Stage I 90–95%, Stage III 40–60%, Stage IV 5–10%",
    ],
  },
]);

// ═══════════════════════════════════════════════════════════════════════════════
//  5. INFLAMMATORY BOWEL DISEASE
// ═══════════════════════════════════════════════════════════════════════════════
sectionHeader("5. Inflammatory Bowel Disease (IBD)", "Crohn's Disease & Ulcerative Colitis — chronic idiopathic gut inflammation");

contentSlide("IBD — Clinical Features & Diagnosis", [
  {
    heading: "Ulcerative Colitis (UC)",
    bullets: [
      "Continuous mucosal inflammation from rectum proximally",
      "Bloody diarrhoea — cardinal symptom",
      "Urgency, tenesmus, mucus in stool",
      "Abdominal cramps, crampy left-sided pain",
      "Fever, weight loss in severe attacks",
      "Toxic megacolon: fever, tachycardia, abdominal distension (emergency)",
      "Extra-intestinal: primary sclerosing cholangitis (UC-specific), iritis, erythema nodosum, pyoderma gangrenosum, arthropathy",
      "Truelove & Witts criteria: mild/moderate/severe UC",
    ],
  },
  {
    heading: "Crohn's Disease (CD)",
    bullets: [
      "Transmural, skip-lesion inflammation; any GI segment",
      "Most common: terminal ileum + right colon (ileocolic)",
      "Abdominal pain (RIF), diarrhoea (may be non-bloody)",
      "Weight loss, malnutrition, malabsorption",
      "Perianal disease: fissures, fistulae, abscesses",
      "Strictures → partial/complete small bowel obstruction",
      "Entero-enteric, entero-vesical, entero-vaginal fistulae",
      "Mouth ulcers, cobblestoning on endoscopy, skip lesions, transmural granulomas",
    ],
  },
  {
    heading: "Investigations",
    bullets: [
      "Bloods: FBC (anaemia, leukocytosis), CRP/ESR, albumin, LFTs, B12",
      "Stool: MC&S, C. difficile, faecal calprotectin (inflammatory marker)",
      "Colonoscopy + biopsies: key diagnostic tool; assess extent/severity",
      "Small bowel MRI (MRE): Crohn's small bowel disease",
      "CT abdomen/pelvis: complications (abscess, perforation, obstruction)",
      "Capsule endoscopy: small bowel Crohn's (ensure no stricture first)",
      "ASCA (Crohn's), p-ANCA (UC): limited diagnostic utility",
      "Plain AXR: in severe/acute UC — assess for dilatation, perforation",
    ],
  },
]);

contentSlide("IBD — Medical & Surgical Treatment", [
  {
    heading: "Medical Treatment",
    bullets: [
      "UC induction: 5-ASA (mesalazine) oral+topical for mild-moderate",
      "Severe UC: IV hydrocortisone (inpatient); ciclosporin/infliximab rescue",
      "UC maintenance: 5-ASA; azathioprine/mercaptopurine",
      "CD induction: prednisolone; budesonide for ileocolic CD",
      "Biologics: infliximab, adalimumab (anti-TNF) for moderate-severe CD & UC",
      "Vedolizumab (anti-α4β7): gut-selective biologic",
      "Ustekinumab (anti-IL12/23): CD maintenance",
      "Exclusive enteral nutrition (EEN): CD remission induction in children",
    ],
  },
  {
    heading: "Surgical Treatment — UC",
    bullets: [
      "Indications: acute severe UC not responding to medical therapy, toxic megacolon, perforation, haemorrhage, dysplasia/cancer, chronic refractory disease",
      "Emergency: subtotal colectomy + end ileostomy (safest in acutely ill)",
      "Elective: restorative proctocolectomy + IPAA (ileal pouch-anal anastomosis) — gold standard",
      "Pouch construction: J-pouch, S-pouch or W-pouch",
      "Defunctioning loop ileostomy routinely used; closed 8–12 weeks later",
      "Proctocolectomy + permanent ileostomy: if poor sphincter function, elderly, or pouch failure",
    ],
  },
  {
    heading: "Surgical Treatment — Crohn's",
    bullets: [
      "Surgery does not cure Crohn's — 70–80% require surgery in lifetime",
      "Principle: bowel-conserving surgery (strictureplasty preferred over resection)",
      "Ileocaecal resection: most common — for terminal ileal disease",
      "Strictureplasty (Finney/Heineke-Mikulicz): for short/multiple strictures",
      "Segmental colonic resection: for colonic disease",
      "Subtotal colectomy + IRA: selected Crohn's colitis",
      "Perianal Crohn's: examine under anaesthesia, seton drainage, fistulotomy, advancement flap",
      "Intraabdominal abscess: CT-guided drainage first, then elective resection",
    ],
  },
]);

// ═══════════════════════════════════════════════════════════════════════════════
//  6. INFECTIONS OF LARGE INTESTINE
// ═══════════════════════════════════════════════════════════════════════════════
sectionHeader("6. Infections of the Large Intestine", "Bacterial, parasitic and viral causes of infectious colitis");

contentSlide("Infections of Large Intestine — Clinical Features", [
  {
    heading: "Clostridioides difficile (C. diff)",
    bullets: [
      "Gram-positive spore-forming anaerobe; toxin A + B mediated",
      "Risk factors: antibiotics (broad-spectrum), hospitalisation, PPIs, elderly, immunosuppression",
      "Mild-moderate: watery diarrhoea (>3 stools/day), crampy abdominal pain",
      "Severe: fever, leukocytosis (WBC >15×10⁹), raised creatinine",
      "Fulminant: pseudomembranous colitis, toxic megacolon, perforation, septic shock",
      "Diagnosis: stool toxin PCR/EIA; colonoscopy shows pseudomembranes",
      "Recurrent C. difficile infection: major clinical challenge",
    ],
  },
  {
    heading: "Other Infectious Causes",
    bullets: [
      "Amoebic colitis (E. histolytica): bloody mucoid diarrhoea, flask-shaped ulcers, RIF tenderness; amoebic liver abscess",
      "Campylobacter jejuni: most common bacterial gastroenteritis; bloody diarrhoea, crampy pain",
      "Salmonella: non-typhoidal; self-limiting diarrhoea, fever",
      "Shigella: dysentery — bloody mucoid diarrhoea, fever, tenesmus",
      "E. coli O157 (EHEC): haemorrhagic colitis; haemolytic-uraemic syndrome (HUS)",
      "CMV colitis: immunocompromised patients; colonoscopy shows ulcers",
      "Typhlitis/neutropenic colitis: right colon, chemotherapy patients",
    ],
  },
  {
    heading: "Diagnosis",
    bullets: [
      "Stool cultures, microscopy and sensitivity",
      "Stool PCR for C. difficile, E. coli O157, norovirus",
      "Stool ova and parasites (E. histolytica, Giardia)",
      "Serology: anti-amoebic antibodies",
      "Colonoscopy: assess mucosal pattern (pseudomembranes, ulcers, inflammation)",
      "CT abdomen: complications — perforation, abscess, megacolon",
      "FBC, CRP, U&E, LFTs (severity assessment)",
      "Blood cultures if systemic sepsis suspected",
    ],
  },
]);

contentSlide("Infections of Large Intestine — Treatment & Management", [
  {
    heading: "C. difficile Treatment",
    bullets: [
      "Discontinue offending antibiotic if possible",
      "Mild-moderate: oral vancomycin 125 mg QID × 10 days (first-line)",
      "Fidaxomicin 200 mg BD × 10 days: lower recurrence than vancomycin",
      "Severe/fulminant: oral vancomycin 500 mg QID + IV metronidazole",
      "Recurrent C. diff: bezlotoxumab (monoclonal antibody) adjunct",
      "Faecal microbiota transplantation (FMT): highly effective for recurrent C. diff",
      "Surgical: colectomy (subtotal/segmental) for toxic megacolon/perforation",
      "Infection control: hand hygiene (soap+water), contact precautions, environmental disinfection",
    ],
  },
  {
    heading: "Treatment — Other Infections",
    bullets: [
      "Amoebic colitis: metronidazole 800 mg TID × 5–10 days + luminal agent (diloxanide furoate)",
      "Amoebic liver abscess: metronidazole ± aspiration if >5 cm, no response, or left lobe",
      "Campylobacter: usually self-limiting; azithromycin if severe/immunocompromised",
      "Shigella: ciprofloxacin or azithromycin",
      "Non-typhoidal Salmonella: antibiotics if bacteraemia/severe",
      "E. coli O157: supportive (avoid antibiotics — risk of HUS); dialysis if HUS",
      "CMV colitis: ganciclovir (IV) or valganciclovir (oral)",
      "Typhlitis: broad-spectrum antibiotics, bowel rest; surgery if perforation/failed medical treatment",
    ],
  },
  {
    heading: "Surgical Indications & General Management",
    bullets: [
      "Surgery for: toxic megacolon, perforation, uncontrolled haemorrhage",
      "Fulminant C. diff: subtotal colectomy + end ileostomy (standard)",
      "Diverting loop ileostomy + colonic lavage: colostomy-sparing option (selected centres)",
      "Amoebic liver abscess: percutaneous drainage preferred over open",
      "Supportive: IV fluids, electrolyte replacement, nutritional support",
      "Barrier nursing, contact precautions for confirmed/suspected C. diff",
      "Antibiotic stewardship: restrict causative antibiotics in institutional setting",
    ],
  },
]);

// ═══════════════════════════════════════════════════════════════════════════════
//  7. VASCULAR ANOMALIES
// ═══════════════════════════════════════════════════════════════════════════════
sectionHeader("7. Vascular Anomalies of the Large Intestine", "Angiodysplasia · Colonic Ischaemia · Haemorrhoids · AVM");

contentSlide("Vascular Anomalies — Clinical Features", [
  {
    heading: "Angiodysplasia",
    bullets: [
      "Most common vascular lesion of the colon",
      "Ectatic mucosal and submucosal vessels — degenerative",
      "Predominance in right colon/caecum (elderly)",
      "Recurrent painless lower GI bleeding (fresh red blood PR)",
      "Intermittent haematochezia or chronic occult bleeding",
      "Iron-deficiency anaemia from chronic blood loss",
      "Associated with aortic stenosis (Heyde's syndrome)",
      "Associated with chronic renal failure",
    ],
  },
  {
    heading: "Colonic Ischaemia",
    bullets: [
      "Most common ischaemic GI disorder; primarily affects elderly",
      "Local hypoperfusion + reperfusion injury",
      "Watershed areas: splenic flexure (Griffiths' point), rectosigmoid junction",
      "Crampy abdominal pain over affected segment",
      "Bloody diarrhoea within 24 hours (hallmark)",
      "Peritoneal signs if transmural ischaemia/perforation",
      "Risk factors: atherosclerosis, low-flow states, aortic surgery, thrombophilia, vasculitis, cocaine",
      "CT abdomen shows bowel wall thickening, thumbprinting",
    ],
  },
  {
    heading: "Other Vascular Anomalies",
    bullets: [
      "Colonic haemangioma: rare; rectal bleeding, may be diffuse",
      "Hereditary haemorrhagic telangiectasia (HHT/Osler-Weber-Rendu): telangiectasias throughout GI tract",
      "Dieulafoy's lesion: large submucosal artery; rare in colon",
      "Haemorrhoids: internal (painless bleeding) / external (painful perianal swelling)",
      "Rectal varices: portal hypertension; massive PR bleeding",
      "Aorto-enteric fistula: post-aortic surgery, massive haemorrhage",
      "Cavernous haemangioma: large lesion, may require colectomy",
    ],
  },
]);

contentSlide("Vascular Anomalies — Treatment & Management", [
  {
    heading: "Angiodysplasia Treatment",
    bullets: [
      "Colonoscopy: first-line — argon plasma coagulation (APC), bipolar coagulation, clipping",
      "APC (argon plasma coagulation): most widely used endoscopic thermal therapy",
      "Repeat colonoscopy for recurrent lesions",
      "Angiography + transarterial embolisation: for active bleeding, failed endoscopy",
      "Somatostatin analogues (octreotide): reduce recurrence in recurrent angiodysplasia",
      "Surgical resection (right hemicolectomy): recurrent/massive uncontrolled haemorrhage",
      "Thalidomide: for HHT-related GI angiodysplasia",
      "Iron replacement for chronic anaemia; transfusion for significant haemorrhage",
    ],
  },
  {
    heading: "Colonic Ischaemia Treatment",
    bullets: [
      "Most cases self-limiting — supportive management",
      "Bowel rest (NPO), IV fluids, analgesia",
      "Broad-spectrum antibiotics for transmural ischaemia",
      "Discontinue vasopressors, NSAIDs, constipating medications",
      "Colonoscopy within 48 hours: confirms diagnosis, assesses extent",
      "Serial abdominal exams and imaging to monitor progression",
      "Surgical intervention: peritonitis, full-thickness necrosis, perforation, clinical deterioration",
      "Segmental colectomy with end-colostomy (Hartmann's) in emergency",
    ],
  },
  {
    heading: "Haemorrhoids & Other",
    bullets: [
      "Grade I–II haemorrhoids: dietary advice (fibre, fluid), rubber band ligation, injection sclerotherapy",
      "Grade III haemorrhoids: rubber band ligation, stapled haemorrhoidopexy, Doppler-guided haemorrhoidal artery ligation (DGHAL)",
      "Grade IV/thrombosed: haemorrhoidectomy (Milligan-Morgan / Ferguson)",
      "Rectal varices: portosystemic shunting, TIPS, band ligation",
      "HHT: laser/APC therapy, antifibrinolytics, bevacizumab (anti-VEGF)",
      "Colonic haemangioma: endoscopic treatment or surgical resection",
      "Postoperative colonic ischaemia (post-aortic surgery): segmental resection",
    ],
  },
]);

// ═══════════════════════════════════════════════════════════════════════════════
//  8. CONSTIPATION
// ═══════════════════════════════════════════════════════════════════════════════
sectionHeader("8. Constipation", "Functional & organic — affecting 15–20% of general population");

contentSlide("Constipation — Clinical Features & Diagnosis", [
  {
    heading: "Definition & Types",
    bullets: [
      "Rome IV: <3 spontaneous complete bowel movements/week + ≥1 of: straining, lumpy/hard stools, incomplete evacuation, anorectal obstruction, manual manoeuvres",
      "Normal transit constipation (functional constipation)",
      "Slow transit constipation: colonic dysmotility (Hinton's radiopaque marker study)",
      "Outlet/obstructive defaecation: pelvic floor dysfunction, anismus, rectocele",
      "Secondary causes: hypothyroidism, hypercalcaemia, Parkinson's, opioids, tricyclics, CCBs, antacids",
      "Hirschsprung's disease (congenital): absence of ganglion cells — neonates/adults",
    ],
  },
  {
    heading: "Clinical Features",
    bullets: [
      "Infrequent stool passage (<3/week)",
      "Hard, pellet-like stools; excessive straining",
      "Sensation of incomplete evacuation or anorectal blockage",
      "Abdominal bloating, distension, cramping",
      "Faecal impaction in elderly: paradoxical overflow diarrhoea",
      "Stercoral ulcer: pressure necrosis from impacted faeces",
      "Rectal prolapse: from chronic straining",
      "Solitary rectal ulcer syndrome: straining + rectal mucosal prolapse",
    ],
  },
  {
    heading: "Investigations",
    bullets: [
      "History: Rome IV criteria, drug history, dietary fibre intake, fluid intake",
      "Physical exam: abdominal palpation, DRE (anal tone, rectocele, faecal loading)",
      "Bloods: TFTs, calcium, FBC, CRP",
      "Plain AXR: faecal loading extent",
      "Colonic transit study (radiopaque markers): slow-transit vs outlet",
      "Anorectal physiology: anorectal manometry, balloon expulsion test",
      "Defaecating proctogram/MRI defaecography: identify structural causes (rectocele, intussusception)",
      "Colonoscopy: exclude colorectal cancer, strictures",
    ],
  },
]);

contentSlide("Constipation — Treatment & Management", [
  {
    heading: "Medical Treatment",
    bullets: [
      "Dietary: high-fibre diet (25–35 g/day), increased fluid intake",
      "Bulk-forming laxatives: ispaghula husk (psyllium), methylcellulose",
      "Osmotic laxatives: macrogol (polyethylene glycol) — first-line in adults",
      "Stimulant laxatives: senna, bisacodyl — short-term use",
      "Lactulose: osmotic; less effective than macrogol",
      "Prucalopride (5-HT4 agonist): for chronic constipation unresponsive to laxatives",
      "Linaclotide / plecanatide (guanylate cyclase-C agonist): IBS-C and chronic constipation",
      "Biofeedback therapy: first-line for outlet/obstructive defaecation (anismus)",
    ],
  },
  {
    heading: "Surgical Treatment",
    bullets: [
      "Indicated for: slow-transit constipation failing medical treatment, obstructive defaecation refractory to biofeedback",
      "Total colectomy + ileorectal anastomosis (IRA): for pan-colonic slow-transit — best surgical outcome",
      "Subtotal colectomy + caecoproctostomy: alternative",
      "Segmental colectomy: less effective; not routinely recommended",
      "Anterior rectopexy (laparoscopic): for rectal prolapse causing outlet obstruction",
      "STARR procedure (Stapled TransAnal Rectal Resection): for obstructive defaecation with internal intussusception/rectocele",
      "Sacral nerve stimulation: for idiopathic slow-transit, less invasive option",
    ],
  },
  {
    heading: "Management of Complications",
    bullets: [
      "Faecal impaction: phosphate/warm water enemas, manual disimpaction under sedation",
      "Stercoral ulcer: bowel rest, fluids, treat underlying impaction; surgery if perforated",
      "Rectal prolapse: Altemeier's procedure (perineal rectosigmoidectomy) or Delorme's procedure",
      "Hirschsprung's disease: pull-through procedure (Swenson/Soave/Duhamel)",
      "Sigmoid volvulus: flexible sigmoidoscopic decompression; elective sigmoid colectomy post-decompression",
      "Solitary rectal ulcer: biofeedback, high-fibre; rectopexy if full-thickness prolapse",
    ],
  },
]);

// ═══════════════════════════════════════════════════════════════════════════════
//  9. IRRITABLE BOWEL SYNDROME
// ═══════════════════════════════════════════════════════════════════════════════
sectionHeader("9. Irritable Bowel Syndrome (IBS)", "Chronic functional bowel disorder — 7–21% of the general population");

contentSlide("IBS — Clinical Features & Diagnosis", [
  {
    heading: "Definition & Pathophysiology",
    bullets: [
      "Chronic functional disorder: abdominal pain + altered bowel habit without structural/biochemical cause",
      "Affects 7–21% of population; female predominance (2:1)",
      "Pathophysiology: gut microbiome alteration, increased intestinal permeability, altered gut motility, visceral hypersensitivity, brain-gut axis dysregulation",
      "Post-infectious IBS: 10–30% after acute gastroenteritis",
      "Subtypes: IBS-D (diarrhoea), IBS-C (constipation), IBS-M (mixed), unsubtyped",
      "Increased gas production from altered microbiome → bowel distension",
    ],
  },
  {
    heading: "Clinical Features",
    bullets: [
      "Recurrent abdominal pain (crampy, lower abdominal, relieved by defaecation)",
      "Bloating and abdominal distension",
      "Diarrhoea and/or constipation; altered stool consistency (Bristol Stool Scale)",
      "Mucus in stool (without blood)",
      "Urgency, feeling of incomplete evacuation",
      "Symptoms worse after eating (gastrocolic reflex)",
      "Symptom exacerbation with stress/anxiety",
      "Absence of rectal bleeding, nocturnal symptoms, or constitutional symptoms (red flags)",
    ],
  },
  {
    heading: "Rome IV Criteria & Diagnosis",
    bullets: [
      "Recurrent abdominal pain ≥1 day/week (last 3 months); onset ≥6 months before diagnosis",
      "Pain related to defaecation; AND/OR change in stool frequency; AND/OR change in stool form",
      "Requires ≥2 of the 3 criteria above",
      "RED FLAGS requiring investigation: age >50, no prior CRC screening, rectal bleeding, nocturnal pain, unintentional weight loss, family history CRC/IBD, palpable mass, iron-deficiency anaemia",
      "Investigations: FBC, CRP, coeliac serology, faecal calprotectin, stool culture",
      "Colonoscopy if red flags present or diagnostic uncertainty",
      "IBS is NOT a diagnosis of exclusion under Rome IV — positive symptom-based diagnosis",
    ],
  },
]);

contentSlide("IBS — Treatment & Management", [
  {
    heading: "Dietary & Lifestyle",
    bullets: [
      "Low-FODMAP diet: highly effective — reduces fermentable carbohydrates",
      "Regular meals, avoid large meals, reduce fizzy drinks",
      "Probiotics: some evidence for symptom relief (Lactobacillus, Bifidobacterium)",
      "Soluble fibre (ispaghula): IBS-C",
      "Avoid insoluble fibre (bran) — may worsen bloating",
      "Stress management, regular exercise",
      "Cognitive Behavioural Therapy (CBT): effective for refractory IBS",
      "Gut-directed hypnotherapy: evidence-based psychological treatment",
    ],
  },
  {
    heading: "Medical Treatment",
    bullets: [
      "IBS-D: loperamide, rifaximin (non-absorbable antibiotic), alosetron (5-HT3 antagonist — women)",
      "IBS-C: macrogol, linaclotide, prucalopride (5-HT4 agonist)",
      "Antispasmodics: mebeverine, hyoscine butylbromide — for abdominal cramping",
      "Peppermint oil: smooth muscle relaxant, reduces pain/bloating",
      "Low-dose tricyclic antidepressants (amitriptyline 10–30 mg): visceral analgesia (all subtypes)",
      "SSRIs: for IBS-D and psychological comorbidity",
      "Eluxadoline (μ-opioid agonist/δ-antagonist): IBS-D",
    ],
  },
  {
    heading: "Surgery & Advanced Management",
    bullets: [
      "Surgery has NO established role in IBS — functional disorder",
      "Colectomy/resection NOT recommended (worsens outcome)",
      "Ensure differential diagnoses excluded before surgical referral: IBD, CRC, endometriosis, coeliac",
      "Neuromodulation (sacral nerve stimulation): experimental for refractory IBS",
      "FMT (faecal microbiota transplant): investigational — mixed results",
      "Multidisciplinary approach: gastroenterologist, dietitian, psychologist",
      "Patient education and reassurance: cornerstone of management",
      "Regular follow-up with symptom diary and response monitoring",
    ],
  },
]);

// ═══════════════════════════════════════════════════════════════════════════════
//  SUMMARY / CONCLUSION
// ═══════════════════════════════════════════════════════════════════════════════
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    { num: "3", label: "Lynch Syndrome", text: "MMR gene defect (MLH1/MSH2) — subtotal colectomy; aspirin reduces CRC risk (CAPP2)" },
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cd /home/daytona/workspace/surgery-pptx && node build.js 2>&1

ls -lh /home/daytona/workspace/surgery-pptx/Large_Intestine_Surgery.pptx && pyth…