const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Mesenteric Ischemia – Comprehensive Surgical Review";
pres.author = "Surgical Education";

// ─────────────────────────────────────────────
// COLOUR PALETTE  (clean, clinical, white background)
// ─────────────────────────────────────────────
const C = {
  navy:     "1A3557",   // dark navy – title bars, headers
  teal:     "1A7A8A",   // teal accent – section banners
  red:      "C0392B",   // danger / warning callouts
  orange:   "E67E22",   // amber highlights
  green:    "1E8449",   // good outcomes
  lightBg:  "F0F4F8",   // slide background (very light blue-grey)
  white:    "FFFFFF",
  darkText: "1A2332",
  midText:  "2C3E50",
  subText:  "4A5568",
  tableHdr: "1A3557",
  tableRow: "EAF0F6",
  tableAlt: "FFFFFF",
  border:   "B0BEC5",
};

// ─────────────────────────────────────────────
// HELPERS
// ─────────────────────────────────────────────
function addSlide(bg) {
  const sl = pres.addSlide();
  sl.background = { color: bg || C.lightBg };
  return sl;
}

function sectionBanner(slide, label) {
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.45, fill: { color: C.teal }, line: { color: C.teal } });
  slide.addText(label.toUpperCase(), {
    x: 0.18, y: 0.04, w: 9.6, h: 0.38,
    fontSize: 9, bold: true, color: C.white, charSpacing: 2
  });
}

function slideTitle(slide, title, sub) {
  // navy bar at top
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0.45, w: 10, h: 0.72, fill: { color: C.navy }, line: { color: C.navy } });
  slide.addText(title, {
    x: 0.25, y: 0.47, w: 9.5, h: 0.66,
    fontSize: 22, bold: true, color: C.white, valign: "middle"
  });
  if (sub) {
    slide.addText(sub, {
      x: 0.25, y: 1.22, w: 9.5, h: 0.32,
      fontSize: 11, color: C.teal, italic: true
    });
  }
}

function bullet(text, indent, bold) {
  return {
    text,
    options: {
      bullet: { indent: indent || 10 },
      fontSize: 13,
      color: bold ? C.navy : C.darkText,
      bold: !!bold,
      breakLine: true,
      paraSpaceAfter: 3,
    }
  };
}

function divider(slide, y) {
  slide.addShape(pres.ShapeType.line, {
    x: 0.3, y, w: 9.4, h: 0,
    line: { color: C.border, width: 0.8 }
  });
}

// ─────────────────────────────────────────────
// 1. TITLE SLIDE
// ─────────────────────────────────────────────
{
  const sl = addSlide(C.navy);
  // decorative top stripe
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.18, fill: { color: C.teal }, line: { color: C.teal } });
  // large white title
  sl.addText("MESENTERIC ISCHEMIA", {
    x: 0.6, y: 0.9, w: 8.8, h: 1.1,
    fontSize: 42, bold: true, color: C.white, align: "center", charSpacing: 3
  });
  sl.addShape(pres.ShapeType.rect, { x: 2.5, y: 2.1, w: 5, h: 0.07, fill: { color: C.teal }, line: { color: C.teal } });
  sl.addText("A COMPREHENSIVE SURGICAL REVIEW", {
    x: 0.5, y: 2.25, w: 9, h: 0.55,
    fontSize: 17, color: C.teal, align: "center", charSpacing: 1.5
  });
  sl.addText([
    { text: "Presenter: Dr. Jeet Vaghasiya (R3SU1)  |  ", options: { fontSize: 12, color: "A8C0D6" } },
    { text: "Chairperson: Dr. Ketan Mehta (MS), Dr. Girish Parmar (MS)", options: { fontSize: 12, color: "A8C0D6" } }
  ], { x: 0.5, y: 3.1, w: 9, h: 0.4, align: "center" });
  sl.addText("Based on: Schwartz's Principles of Surgery 11e  ·  Sabiston Textbook of Surgery  ·  Current Surgical Therapy 14e", {
    x: 0.5, y: 3.65, w: 9, h: 0.4,
    fontSize: 9.5, color: "7A9BBF", align: "center", italic: true
  });
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 5.2, w: 10, h: 0.42, fill: { color: "122540" }, line: { color: "122540" } });
  sl.addText("General Surgery · 2026", {
    x: 0.5, y: 5.22, w: 9, h: 0.36,
    fontSize: 10, color: "7A9BBF", align: "center"
  });
}

// ─────────────────────────────────────────────
// 2. LECTURE OUTLINE
// ─────────────────────────────────────────────
{
  const sl = addSlide();
  sectionBanner(sl, "Overview");
  slideTitle(sl, "Lecture Outline", null);

  const topics = [
    "1.  Introduction & Historical Perspective",
    "2.  Epidemiology & Mortality Data",
    "3.  Vascular Anatomy — SMA & Collaterals",
    "4.  Classification of Mesenteric Ischemia",
    "5.  Pathophysiology — Ischemia Timeline",
    "6.  Embolic vs. Thrombotic vs. NOMI vs. MVT",
    "7.  Clinical Presentation & Differential Diagnosis",
    "8.  Diagnostic Investigations (Labs + CTA)",
    "9.  Surgical & Endovascular Management of AMI",
    "10. Chronic Mesenteric Ischemia — Workup & Revascularization",
    "11. Special Scenarios, Complications & Outcomes",
  ];

  const col1 = topics.slice(0, 6);
  const col2 = topics.slice(6);

  const mkItems = (arr) => arr.map(t => ({ text: t, options: { fontSize: 13, color: C.darkText, bullet: { indent: 8 }, breakLine: true, paraSpaceAfter: 5 } }));

  sl.addText(mkItems(col1), { x: 0.3, y: 1.58, w: 4.6, h: 3.8 });
  sl.addShape(pres.ShapeType.line, { x: 5.0, y: 1.6, w: 0, h: 3.7, line: { color: C.border, width: 0.8 } });
  sl.addText(mkItems(col2), { x: 5.15, y: 1.58, w: 4.6, h: 3.8 });
}

// ─────────────────────────────────────────────
// 3. HISTORICAL MILESTONES TABLE
// ─────────────────────────────────────────────
{
  const sl = addSlide();
  sectionBanner(sl, "Section 1 — Introduction & Epidemiology");
  slideTitle(sl, "Historical Perspective & Epidemiology");

  // Table
  const rows = [
    [{ text: "Year", options: { bold: true, color: C.white, fill: { color: C.tableHdr } } },
     { text: "Milestone", options: { bold: true, color: C.white, fill: { color: C.tableHdr } } }],
    ["1869", "First description of mesenteric ischemia — Chienne"],
    ["1895", "First intestinal resection & reanastomosis — Elliot"],
    ["1951", "First SMA embolectomy — Klass"],
    ["1957", "First successful embolectomy without bowel resection — Shaw & Maynard"],
    ["1980s", "Endovascular treatment of mesenteric disease introduced"],
    ["2000s+", "Endovascular-first strategies; improved CT imaging — paradigm shift"],
  ];

  sl.addTable(rows, {
    x: 0.3, y: 1.6, w: 9.4, h: 3.4,
    colW: [1.2, 8.2],
    border: { type: "solid", color: C.border, pt: 0.5 },
    fill: { color: C.tableAlt },
    rowH: 0.44,
    fontFace: "Calibri",
    fontSize: 12,
    color: C.darkText,
    align: "left",
    valign: "middle",
  });

  // Epi callout box bottom
  sl.addShape(pres.ShapeType.rect, { x: 0.3, y: 5.05, w: 9.4, h: 0.45,
    fill: { color: "EBF5FB" }, line: { color: C.teal, width: 1 } });
  sl.addText("Epidemiology: < 1/100,000 admissions · Median age 74 yrs · Incidence doubles per 5-yr interval >70 · 3× higher in females · Overall AMI mortality ~17–21%", {
    x: 0.4, y: 5.07, w: 9.2, h: 0.4,
    fontSize: 10.5, color: C.teal, italic: false
  });
}

// ─────────────────────────────────────────────
// 4. CLASSIFICATION TABLE
// ─────────────────────────────────────────────
{
  const sl = addSlide();
  sectionBanner(sl, "Section 3 — Classification");
  slideTitle(sl, "Classification of Mesenteric Ischemia");

  const rows = [
    [
      { text: "Type", options: { bold: true, color: C.white, fill: { color: C.tableHdr } } },
      { text: "% of AMI", options: { bold: true, color: C.white, fill: { color: C.tableHdr } } },
      { text: "Mechanism", options: { bold: true, color: C.white, fill: { color: C.tableHdr } } },
      { text: "Key Feature", options: { bold: true, color: C.white, fill: { color: C.tableHdr } } },
    ],
    [
      { text: "Arterial Embolism", options: { bold: true } },
      "40–50%",
      "Cardiac source → SMA lodging",
      "Abrupt onset; proximal jejunum/R colon spared"
    ],
    [
      { text: "Arterial Thrombosis", options: { bold: true } },
      "20–35%",
      "Atherosclerotic occlusion at SMA origin",
      "History of CMI symptoms; diffuse ischemia"
    ],
    [
      { text: "NOMI", options: { bold: true } },
      "~20%",
      "Mesenteric vasoconstriction; low-flow state",
      "ICU patients; vasopressors; no occlusion on CTA"
    ],
    [
      { text: "Mesenteric Venous Thrombosis", options: { bold: true } },
      "5–15%",
      "Portal/SMV thrombosis → venous hypertension",
      "Subacute; anticoagulation; best prognosis"
    ],
    [
      { text: "Chronic MI (CMI)", options: { bold: true } },
      "—",
      "Progressive atherosclerosis ≥2 visceral vessels",
      "Food fear; weight loss; postprandial pain"
    ],
  ];

  sl.addTable(rows, {
    x: 0.2, y: 1.58, w: 9.6, h: 3.8,
    colW: [2.1, 1.0, 3.4, 3.1],
    border: { type: "solid", color: C.border, pt: 0.5 },
    fill: { color: C.tableAlt },
    rowH: 0.6,
    fontFace: "Calibri",
    fontSize: 11.5,
    color: C.darkText,
    align: "left",
    valign: "middle",
  });
}

// ─────────────────────────────────────────────
// 5. VASCULAR ANATOMY
// ─────────────────────────────────────────────
{
  const sl = addSlide();
  sectionBanner(sl, "Section 2 — Vascular Anatomy");
  slideTitle(sl, "Mesenteric Vascular Anatomy & Collaterals");

  // Left panel – anatomy text
  sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.58, w: 4.55, h: 0.32,
    fill: { color: C.navy }, line: { color: C.navy } });
  sl.addText("Three Major Mesenteric Arteries", {
    x: 0.3, y: 1.59, w: 4.45, h: 0.3,
    fontSize: 11, bold: true, color: C.white
  });

  sl.addText([
    bullet("Celiac Artery — foregut (stomach → proximal duodenum, liver, spleen)", 10),
    bullet("Superior Mesenteric Artery (SMA) — midgut (distal duodenum → 2/3 transverse colon)", 10),
    bullet("Inferior Mesenteric Artery (IMA) — hindgut (splenic flexure → rectum)", 10),
    bullet("SMA: 2nd branch of aorta; oblique angle → thromboemboli preferentially lodge here", 10),
    bullet("50% of emboli settle distal to middle colic a. origin", 10),
  ], { x: 0.3, y: 1.92, w: 4.45, h: 2.0 });

  divider(sl, 3.95);

  sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 4.0, w: 4.55, h: 0.32,
    fill: { color: C.teal }, line: { color: C.teal } });
  sl.addText("Key Collateral Pathways", {
    x: 0.3, y: 4.01, w: 4.45, h: 0.3,
    fontSize: 11, bold: true, color: C.white
  });
  sl.addText([
    bullet("Celiac ↔ SMA: Pancreaticoduodenal arcade", 10),
    bullet("SMA ↔ IMA: Marginal artery of Drummond", 10),
    bullet("SMA ↔ IMA: Arc of Riolan (meandering mesenteric a.)", 10),
    bullet("IMA ↔ Internal iliac: Hemorrhoidal arteries", 10),
  ], { x: 0.3, y: 4.34, w: 4.45, h: 1.2 });

  // Right panel – anatomy diagram (shapes)
  sl.addShape(pres.ShapeType.rect, { x: 5.05, y: 1.58, w: 4.7, h: 4.0,
    fill: { color: "EBF5FB" }, line: { color: C.border } });
  sl.addText("MESENTERIC ARTERIAL TREE", {
    x: 5.1, y: 1.65, w: 4.6, h: 0.3,
    fontSize: 10, bold: true, color: C.navy, align: "center"
  });

  // Aorta (vertical bar)
  sl.addShape(pres.ShapeType.rect, { x: 7.3, y: 2.1, w: 0.18, h: 3.1,
    fill: { color: C.navy }, line: { color: C.navy } });
  sl.addText("AORTA", { x: 7.52, y: 3.4, w: 0.8, h: 0.25, fontSize: 8, bold: true, color: C.navy });

  // Celiac
  sl.addShape(pres.ShapeType.line, { x: 6.25, y: 2.25, w: 1.05, h: 0, line: { color: C.teal, width: 2 } });
  sl.addShape(pres.ShapeType.ellipse, { x: 5.55, y: 2.12, w: 0.72, h: 0.28, fill: { color: C.teal }, line: { color: C.teal } });
  sl.addText("Celiac", { x: 5.55, y: 2.14, w: 0.72, h: 0.24, fontSize: 8, bold: true, color: C.white, align: "center" });

  // SMA
  sl.addShape(pres.ShapeType.line, { x: 6.25, y: 3.0, w: 1.05, h: 0, line: { color: C.orange, width: 2.5 } });
  sl.addShape(pres.ShapeType.ellipse, { x: 5.45, y: 2.87, w: 0.85, h: 0.28, fill: { color: C.orange }, line: { color: C.orange } });
  sl.addText("SMA", { x: 5.45, y: 2.89, w: 0.85, h: 0.24, fontSize: 9, bold: true, color: C.white, align: "center" });

  // IMA
  sl.addShape(pres.ShapeType.line, { x: 6.25, y: 3.75, w: 1.05, h: 0, line: { color: C.green, width: 2 } });
  sl.addShape(pres.ShapeType.ellipse, { x: 5.55, y: 3.62, w: 0.72, h: 0.28, fill: { color: C.green }, line: { color: C.green } });
  sl.addText("IMA", { x: 5.55, y: 3.64, w: 0.72, h: 0.24, fontSize: 8, bold: true, color: C.white, align: "center" });

  // Collateral arrows
  sl.addShape(pres.ShapeType.line, { x: 5.9, y: 2.72, w: 0, h: 0.2, line: { color: C.red, width: 1.5 } });
  sl.addText("↕ Collateral", { x: 5.75, y: 2.9, w: 1.1, h: 0.2, fontSize: 7.5, color: C.red, italic: true });
  sl.addShape(pres.ShapeType.line, { x: 5.9, y: 3.46, w: 0, h: 0.2, line: { color: C.red, width: 1.5 } });
  sl.addText("↕ Collateral", { x: 5.75, y: 3.65, w: 1.1, h: 0.2, fontSize: 7.5, color: C.red, italic: true });

  sl.addText("Clinical pearl: Ischemia typically requires ≥2 of 3 vessels to be compromised due to abundant collaterals", {
    x: 5.1, y: 4.8, w: 4.55, h: 0.55,
    fontSize: 9.5, color: C.red, italic: true, wrap: true
  });
}

// ─────────────────────────────────────────────
// 6. PATHOPHYSIOLOGY TIMELINE
// ─────────────────────────────────────────────
{
  const sl = addSlide();
  sectionBanner(sl, "Section 4 — Pathophysiology");
  slideTitle(sl, "Pathophysiology — Ischemia Timeline", '"Time is Bowel — Minutes Matter"');

  // Timeline flowchart using shapes
  const boxes = [
    { label: "0 – 3 hrs", desc: "Mucosal sloughing\nBacterial translocation\nVillous tip necrosis", color: C.orange },
    { label: "3 – 6 hrs", desc: "Full-thickness\nischemia begins\nWall oedema, haemorrhage", color: "E74C3C" },
    { label: "> 6 hrs", desc: "FULL-THICKNESS\nINFARCTION\nIrreversible necrosis", color: C.red },
    { label: "Late / Untreated", desc: "Peritonitis\nSeptic shock\nMulti-organ failure\nDEATH", color: "7B241C" },
  ];

  boxes.forEach((b, i) => {
    const x = 0.35 + i * 2.38;
    // Box
    sl.addShape(pres.ShapeType.rect, { x, y: 1.72, w: 2.1, h: 1.6,
      fill: { color: b.color }, line: { color: b.color } });
    sl.addText(b.label, { x, y: 1.74, w: 2.1, h: 0.36, fontSize: 12, bold: true, color: C.white, align: "center" });
    sl.addText(b.desc, { x, y: 2.12, w: 2.1, h: 1.16, fontSize: 10.5, color: C.white, align: "center", valign: "middle", wrap: true });
    // Arrow
    if (i < 3) {
      sl.addShape(pres.ShapeType.line, { x: x + 2.1, y: 2.52, w: 0.28, h: 0, line: { color: C.midText, width: 2 } });
      sl.addText("▶", { x: x + 2.14, y: 2.43, w: 0.2, h: 0.2, fontSize: 10, color: C.midText });
    }
  });

  // Cascade box
  sl.addShape(pres.ShapeType.rect, { x: 0.3, y: 3.5, w: 9.4, h: 0.32,
    fill: { color: C.navy }, line: { color: C.navy } });
  sl.addText("PATHOPHYSIOLOGICAL CASCADE", {
    x: 0.35, y: 3.51, w: 9.3, h: 0.3,
    fontSize: 11, bold: true, color: C.white, charSpacing: 1.5
  });

  sl.addText([
    { text: "Reduced intestinal blood flow  →  ", options: { fontSize: 12, color: C.darkText } },
    { text: "Mucosal hypoxia  →  ", options: { fontSize: 12, color: C.orange } },
    { text: "Villous tip necrosis  →  ", options: { fontSize: 12, color: "E74C3C" } },
    { text: "Barrier disruption  →  ", options: { fontSize: 12, color: C.red } },
    { text: "Bacterial translocation  →  ", options: { fontSize: 12, color: "7B241C" } },
    { text: "Cytokine release  →  MODS", options: { fontSize: 12, bold: true, color: "7B241C" } },
  ], { x: 0.3, y: 3.85, w: 9.4, h: 0.45, wrap: true });

  // Reperfusion injury box
  sl.addShape(pres.ShapeType.rect, { x: 0.3, y: 4.38, w: 9.4, h: 0.95,
    fill: { color: "FDFEFE" }, line: { color: C.orange, width: 1.5 } });
  sl.addText([
    { text: "⚠  Reperfusion Injury:  ", options: { bold: true, fontSize: 12, color: C.orange } },
    { text: "Restoration of blood flow → xanthine oxidase activation → superoxide radicals → lipid peroxidation → endothelial damage.  ", options: { fontSize: 11.5, color: C.darkText } },
    { text: "Injury can EXCEED the original ischaemic insult.", options: { bold: true, fontSize: 11.5, color: C.red } },
  ], { x: 0.45, y: 4.43, w: 9.1, h: 0.8, wrap: true });
}

// ─────────────────────────────────────────────
// 7. EMBOLIC vs THROMBOTIC TABLE
// ─────────────────────────────────────────────
{
  const sl = addSlide();
  sectionBanner(sl, "Section 4 — Pathophysiology");
  slideTitle(sl, "Embolic vs. Thrombotic AMI — Key Differences");

  const rows = [
    [
      { text: "Feature", options: { bold: true, color: C.white, fill: { color: C.tableHdr } } },
      { text: "Arterial EMBOLISM", options: { bold: true, color: C.white, fill: { color: "1A6080" } } },
      { text: "Arterial THROMBOSIS", options: { bold: true, color: C.white, fill: { color: "7B3A10" } } },
    ],
    ["% of AMI", "40–50%", "20–35%"],
    ["Source", "Cardiac (AF, LV thrombus, valvular)", "Atherosclerotic plaque at SMA origin"],
    ["Onset", "ABRUPT — no collateral protection", "Acute on chronic (gradual collaterals present)"],
    ["Location of lodging", "50% distal to middle colic a.; 15% at SMA origin", "SMA origin / proximal CA; pre-existing stenosis"],
    ["Bowel at risk", "Mid-jejunum → ascending colon; proximal jejunum SPARED", "Near-total small bowel (including proximal jejunum)"],
    ["Prior symptoms", "Usually none — sudden event", "Often history of post-prandial pain, weight loss"],
    ["Associated cardiac Dx", "95% have cardiac disease; 68% simultaneous emboli elsewhere", "Generalised PVD, renal artery disease, prior vascular Sx"],
    ["Operative approach", "SMA embolectomy (transverse arteriotomy)", "Bypass (antegrade / retrograde) or endarterectomy"],
  ];

  sl.addTable(rows, {
    x: 0.2, y: 1.6, w: 9.6, h: 3.9,
    colW: [2.2, 3.7, 3.7],
    border: { type: "solid", color: C.border, pt: 0.5 },
    fill: { color: C.tableAlt },
    rowH: 0.43,
    fontFace: "Calibri",
    fontSize: 10.8,
    color: C.darkText,
    align: "left",
    valign: "middle",
  });
}

// ─────────────────────────────────────────────
// 8. NOMI + MVT TABLE
// ─────────────────────────────────────────────
{
  const sl = addSlide();
  sectionBanner(sl, "Section 4 — Pathophysiology");
  slideTitle(sl, "NOMI & Mesenteric Venous Thrombosis");

  // NOMI left
  sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.6, w: 4.6, h: 0.35,
    fill: { color: C.teal }, line: { color: C.teal } });
  sl.addText("NOMI — Non-Occlusive Mesenteric Ischemia (~20%)", {
    x: 0.3, y: 1.61, w: 4.5, h: 0.32,
    fontSize: 10.5, bold: true, color: C.white
  });
  sl.addText([
    bullet("Mechanism: Mesenteric vasoconstriction + intestinal hypoxaemia + reperfusion injury", 8),
    bullet("Low-flow state: body prioritises cardiac/cerebral perfusion at expense of gut", 8),
    bullet("Triggers: Cardiogenic shock, hypovolaemia, vasopressors, digitalis toxicity, dialysis, post-cardiac surgery, severe sepsis", 8),
    bullet("CTA: No occlusion — 'pruning' of mesenteric vessels, vasospasm pattern", 8),
    bullet("Treatment: Treat underlying cause + intra-arterial papaverine/vasodilators", 8),
    bullet("Surgery only if peritonitis or bowel necrosis", 8),
  ], { x: 0.3, y: 1.98, w: 4.5, h: 3.45 });

  // MVT right
  sl.addShape(pres.ShapeType.rect, { x: 5.15, y: 1.6, w: 4.6, h: 0.35,
    fill: { color: C.navy }, line: { color: C.navy } });
  sl.addText("Mesenteric Venous Thrombosis (5–15%)", {
    x: 5.2, y: 1.61, w: 4.5, h: 0.32,
    fontSize: 10.5, bold: true, color: C.white
  });
  sl.addText([
    bullet("Mechanism: Portal/SMV thrombosis → venous hypertension → bowel wall oedema & ischaemia", 8),
    bullet("Risk factors: Hypercoagulable state (Factor V Leiden, protein C/S deficiency, JAK2), portal HTN, malignancy, OCP, abdominal sepsis", 8),
    bullet("Presentation: Subacute (days–weeks) abdominal pain; often less dramatic than arterial AMI", 8),
    bullet("CTA (venous phase): SMV/portal thrombus; bowel wall thickening; mesenteric fat stranding", 8),
    bullet("Treatment: ANTICOAGULATION (heparin → warfarin/DOAC) — cornerstone", 8),
    bullet("Surgery: Only for frank bowel necrosis; best overall prognosis of all AMI types", 8),
  ], { x: 5.2, y: 1.98, w: 4.5, h: 3.45 });

  sl.addShape(pres.ShapeType.line, { x: 4.97, y: 1.6, w: 0, h: 3.8, line: { color: C.border, width: 0.8 } });
}

// ─────────────────────────────────────────────
// 9. CLINICAL PRESENTATION
// ─────────────────────────────────────────────
{
  const sl = addSlide();
  sectionBanner(sl, "Section 5 — Clinical Presentation");
  slideTitle(sl, "Clinical Presentation", "The diagnosis is clinical first, imaging second");

  // AMI box
  sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.6, w: 4.6, h: 0.35,
    fill: { color: C.red }, line: { color: C.red } });
  sl.addText("ACUTE Mesenteric Ischemia — HALLMARKS", {
    x: 0.3, y: 1.61, w: 4.5, h: 0.32,
    fontSize: 10.5, bold: true, color: C.white
  });
  sl.addText([
    { text: "⚠  Pain OUT OF PROPORTION to physical exam — THE key diagnostic clue\n", options: { bold: true, fontSize: 13, color: C.red, breakLine: true } },
    bullet("Sudden-onset severe periumbilical / mid-abdominal pain", 8),
    bullet("Colicky character early; constant/severe when necrosis develops", 8),
    bullet("Nausea, vomiting, diarrhoea (often bloody)", 8),
    bullet("Early: physical exam surprisingly NORMAL", 8),
    bullet("Late: peritonitis, rigidity, haemodynamic collapse", 8),
    bullet("Risk factors: AF, recent MI, valvular disease, PVD", 8),
  ], { x: 0.3, y: 1.98, w: 4.5, h: 3.42 });

  sl.addShape(pres.ShapeType.line, { x: 4.97, y: 1.6, w: 0, h: 3.85, line: { color: C.border, width: 0.8 } });

  // CMI box
  sl.addShape(pres.ShapeType.rect, { x: 5.15, y: 1.6, w: 4.6, h: 0.35,
    fill: { color: C.navy }, line: { color: C.navy } });
  sl.addText("CHRONIC Mesenteric Ischemia — Classic Triad", {
    x: 5.2, y: 1.61, w: 4.5, h: 0.32,
    fontSize: 10.5, bold: true, color: C.white
  });
  sl.addText([
    bullet("Postprandial abdominal pain — 15–30 min after eating ('intestinal angina')", 8),
    bullet("FOOD FEAR — patient voluntarily restricts eating to avoid pain", 8),
    bullet("Progressive significant weight loss", 8),
    bullet("Often misdiagnosed as malignancy (weight loss misleads clinicians)", 8),
    bullet("3:1 female-to-male ratio", 8),
    { text: "\nMVT: ", options: { bold: true, fontSize: 12, color: C.teal, breakLine: false } },
    { text: "Subacute diffuse abdominal pain (days–weeks); less dramatic onset; may present with GI bleeding", options: { fontSize: 11.5, color: C.darkText, breakLine: true } },
  ], { x: 5.2, y: 1.98, w: 4.5, h: 3.42 });
}

// ─────────────────────────────────────────────
// 10. DIFFERENTIAL DIAGNOSIS TABLE
// ─────────────────────────────────────────────
{
  const sl = addSlide();
  sectionBanner(sl, "Section 5 — Clinical Presentation");
  slideTitle(sl, "Differential Diagnosis — Acute Severe Abdominal Pain");

  sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.6, w: 9.5, h: 0.32,
    fill: { color: C.red }, line: { color: C.red } });
  sl.addText("In any elderly patient with sudden severe abdominal pain + AF or vascular disease: AMI must be ACTIVELY EXCLUDED", {
    x: 0.3, y: 1.62, w: 9.4, h: 0.28,
    fontSize: 10.5, bold: true, color: C.white
  });

  const rows = [
    [
      { text: "Surgical Emergencies", options: { bold: true, color: C.white, fill: { color: "1A3557" } } },
      { text: "GI / Medical Causes", options: { bold: true, color: C.white, fill: { color: "1A7A8A" } } },
      { text: "Vascular Emergencies", options: { bold: true, color: C.white, fill: { color: "922B21" } } },
    ],
    ["Perforated peptic ulcer", "Acute pancreatitis", "Ruptured AAA"],
    ["Bowel obstruction / volvulus", "Severe gastroenteritis", "Aortic dissection"],
    ["Acute appendicitis", "IBD exacerbation", "Ischaemic colitis"],
    ["Acute cholecystitis / cholangitis", "Renal colic / ureteral stone", "Spontaneous SMA dissection"],
    ["Sigmoid volvulus", "Inferior MI (referred pain)", "Median arcuate ligament syndrome"],
  ];

  sl.addTable(rows, {
    x: 0.25, y: 1.97, w: 9.5, h: 3.45,
    colW: [3.16, 3.16, 3.18],
    border: { type: "solid", color: C.border, pt: 0.5 },
    fill: { color: C.tableAlt },
    rowH: 0.55,
    fontFace: "Calibri",
    fontSize: 12,
    color: C.darkText,
    align: "center",
    valign: "middle",
  });
}

// ─────────────────────────────────────────────
// 11. LABORATORY INVESTIGATIONS TABLE
// ─────────────────────────────────────────────
{
  const sl = addSlide();
  sectionBanner(sl, "Section 6 — Investigations");
  slideTitle(sl, "Laboratory Investigations", "Adjuncts only — no single test confirms or excludes AMI");

  const rows = [
    [
      { text: "Investigation", options: { bold: true, color: C.white, fill: { color: C.tableHdr } } },
      { text: "Finding in AMI", options: { bold: true, color: C.white, fill: { color: C.tableHdr } } },
      { text: "Clinical Significance", options: { bold: true, color: C.white, fill: { color: C.tableHdr } } },
    ],
    ["WBC count", "> 15,000 with neutrophilic left shift", "Suggests ischaemia/infarction; non-specific"],
    ["Serum Lactate", "Elevated (may be NORMAL early!)", "Normal lactate CANNOT exclude AMI — poor NPV"],
    ["Metabolic panel / ABG", "Metabolic acidosis, raised anion gap", "Late finding; suggests advanced ischaemia"],
    ["Amylase / Lipase", "Elevated (40–50% of cases)", "Non-specific; also raised in pancreatitis"],
    ["Serum phosphate", "Elevated > 1.5 mmol/L (inorganic phosphate)", "Raised with bowel necrosis; useful adjunct"],
    ["D-dimer", "Often elevated", "High sensitivity, very low specificity"],
    ["LDH / CK", "Elevated with muscle ischaemia", "Supports ischaemic necrosis; non-specific"],
    ["ABG", "pH < 7.35, base excess < -4", "Metabolic acidosis = advanced / widespread ischaemia"],
  ];

  sl.addTable(rows, {
    x: 0.2, y: 1.6, w: 9.6, h: 3.9,
    colW: [2.0, 3.6, 4.0],
    border: { type: "solid", color: C.border, pt: 0.5 },
    fill: { color: C.tableAlt },
    rowH: 0.42,
    fontFace: "Calibri",
    fontSize: 11,
    color: C.darkText,
    align: "left",
    valign: "middle",
  });

  sl.addShape(pres.ShapeType.rect, { x: 0.2, y: 5.55, w: 9.6, h: 0.0 });
}

// ─────────────────────────────────────────────
// 12. IMAGING — CTA GOLD STANDARD
// ─────────────────────────────────────────────
{
  const sl = addSlide();
  sectionBanner(sl, "Section 6 — Investigations");
  slideTitle(sl, "Imaging — CT Angiography (Gold Standard)");

  // CTA key info
  sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.62, w: 5.6, h: 0.35,
    fill: { color: C.navy }, line: { color: C.navy } });
  sl.addText("CTA — Sensitivity 93%, Specificity 96%  |  BIPHASIC protocol (arterial + venous phase)", {
    x: 0.3, y: 1.63, w: 5.5, h: 0.32,
    fontSize: 10, bold: true, color: C.white
  });

  sl.addText([
    bullet("BIPHASIC CTA: arterial phase + delayed venous phase — evaluates both arteries & portal/mesenteric veins", 8),
    { text: "\nCT Findings with >97% Specificity:", options: { bold: true, fontSize: 12, color: C.red, breakLine: true, paraSpaceAfter: 2 } },
    bullet("Pneumatosis intestinalis — intramural gas", 12),
    bullet("Portal venous / SMV gas", 12),
    bullet("SMA or celiac artery occlusion (filling defect)", 12),
    bullet("Arterial embolism — intraluminal filling defect", 12),
    { text: "\nOther Findings:", options: { bold: true, fontSize: 12, color: C.teal, breakLine: true, paraSpaceAfter: 2 } },
    bullet("Bowel wall thickening / thinning (paper-thin = transmural necrosis)", 12),
    bullet("Mesenteric fat stranding", 12),
    bullet("Absent bowel wall enhancement = full-thickness ischaemia", 12),
    bullet("Ascites (peritoneal fluid) — late sign", 12),
  ], { x: 0.3, y: 2.0, w: 5.55, h: 3.4 });

  // Right panel — other modalities
  sl.addShape(pres.ShapeType.rect, { x: 6.1, y: 1.62, w: 3.65, h: 0.35,
    fill: { color: C.teal }, line: { color: C.teal } });
  sl.addText("Other Imaging Modalities", {
    x: 6.15, y: 1.63, w: 3.55, h: 0.32,
    fontSize: 10, bold: true, color: C.white
  });

  const modalities = [
    { name: "Plain X-ray", note: "Initial screen; late: ileus, thumbprinting, pneumatosis, portal gas. NEVER to exclude AMI." },
    { name: "Duplex US", note: "Best for CMI: SMA PSV >275 cm/s = >70% stenosis. Sensitivity 92%, Specificity 96%." },
    { name: "Conventional Angiography", note: "Definitive diagnosis + simultaneous endovascular Rx (thrombolysis, vasodilators)." },
    { name: "MRA", note: "Non-radiation alternative for CMI work-up; limited in acute setting." },
  ];

  let yy = 2.02;
  modalities.forEach(m => {
    sl.addText([
      { text: m.name + ": ", options: { bold: true, fontSize: 11, color: C.navy } },
      { text: m.note, options: { fontSize: 10.5, color: C.darkText } }
    ], { x: 6.1, y: yy, w: 3.65, h: 0.65, wrap: true });
    yy += 0.82;
  });
}

// ─────────────────────────────────────────────
// 13. DIAGNOSTIC FLOWCHART
// ─────────────────────────────────────────────
{
  const sl = addSlide();
  sectionBanner(sl, "Section 6 — Investigations");
  slideTitle(sl, "Diagnostic Algorithm — Suspected AMI");

  // Flowchart using shapes
  function box(sl, x, y, w, h, color, text, textColor, fs) {
    sl.addShape(pres.ShapeType.rect, { x, y, w, h, fill: { color }, line: { color } });
    sl.addText(text, { x, y, w, h, fontSize: fs || 11, bold: true, color: textColor || C.white, align: "center", valign: "middle", wrap: true });
  }
  function arw(sl, x, y, len, vert) {
    if (vert) {
      sl.addShape(pres.ShapeType.line, { x, y, w: 0, h: len, line: { color: C.midText, width: 1.5 } });
    } else {
      sl.addShape(pres.ShapeType.line, { x, y, w: len, h: 0, line: { color: C.midText, width: 1.5 } });
    }
  }

  // Start
  box(sl, 3.5, 1.55, 3.0, 0.44, C.red, "SUSPECTED AMI\nElderly + Abdo Pain", C.white, 10.5);
  arw(sl, 5.0, 1.99, 0, 0.22, true);

  // CTA
  box(sl, 2.8, 2.21, 4.4, 0.44, C.navy, "CT ANGIOGRAPHY (Biphasic CTA)", C.white, 10.5);
  arw(sl, 5.0, 2.65, 0, 0.22, true);

  // Decision diamond (rectangle as proxy)
  box(sl, 2.9, 2.87, 4.2, 0.5, C.orange, "PERITONITIS / Bowel Necrosis?", C.white, 11);

  // YES → left
  arw(sl, 2.9, 3.12, -1.8, 0, false);
  sl.addText("YES", { x: 1.55, y: 3.01, w: 0.6, h: 0.22, fontSize: 10, color: C.red, bold: true });
  box(sl, 0.25, 3.3, 2.65, 0.55, C.red, "EMERGENT\nLAPAROTOMY", C.white, 11);
  arw(sl, 1.57, 3.85, 0, 0.22, true);
  box(sl, 0.25, 4.07, 2.65, 0.55, C.red, "Revascularize FIRST\nResect necrotic bowel\nTemp closure", C.white, 9.5);
  arw(sl, 1.57, 4.62, 0, 0.22, true);
  box(sl, 0.25, 4.84, 2.65, 0.44, "922B21", "Second-look 24–48 hrs", C.white, 10.5);

  // NO → right
  arw(sl, 7.1, 3.12, 1.8, 0, false);
  sl.addText("NO", { x: 7.2, y: 3.01, w: 0.5, h: 0.22, fontSize: 10, color: C.green, bold: true });
  box(sl, 8.9, 3.3, 0.85, 0.55, C.teal, "Consider\nEndovascular", C.white, 8.5);
  arw(sl, 9.32, 3.85, 0, 0.22, true);
  box(sl, 8.6, 4.07, 1.15, 0.55, C.teal, "PTA/Stent\nThrombolysis\nEmbolectomy", C.white, 8.5);

  // Centre - specific paths
  arw(sl, 5.0, 3.37, 0, 0.22, true);
  box(sl, 3.7, 3.59, 2.6, 0.44, C.teal, "Identify Subtype:\nEmbolism / Thrombosis / NOMI / MVT", C.white, 9);
  arw(sl, 5.0, 4.03, 0, 0.22, true);
  box(sl, 3.7, 4.25, 2.6, 0.55, C.navy, "Subtype-directed\nmanagement\n(see next slides)", C.white, 10);
}

// ─────────────────────────────────────────────
// 14. INITIAL MANAGEMENT — RESUSCITATION
// ─────────────────────────────────────────────
{
  const sl = addSlide();
  sectionBanner(sl, "Section 7 — Management of AMI");
  slideTitle(sl, "Initial Management — Resuscitation", "Start Immediately — Do NOT Delay Surgical Planning");

  // Flowchart-style checklist
  const steps = [
    { num: "1", head: "IV Access & Fluids", body: "Large-bore IV access · Crystalloid fluid resuscitation · Haemodynamic monitoring (A-line, CVP, urinary catheter)" },
    { num: "2", head: "Monitoring & Decompression", body: "NG tube decompression · Correct electrolyte abnormalities · Continuous ECG and pulse oximetry" },
    { num: "3", head: "Anticoagulation", body: "IV Unfractionated Heparin (UFH) — prevents further thrombus propagation · Continue throughout perioperative period" },
    { num: "4", head: "Vasopressors — Caution", body: "Avoid vasoconstrictors if possible — worsen mesenteric perfusion · If required for haemodynamic support, use cautiously" },
    { num: "5", head: "Antibiotics", body: "Broad-spectrum cover (gram-negative + anaerobic) — bacterial translocation is early and universal" },
    { num: "6", head: "ICU / Surgical Team", body: "Early surgical/vascular surgery consult · Interventional radiology team on standby for endovascular option" },
  ];

  sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.62, w: 9.5, h: 0.3,
    fill: { color: C.red }, line: { color: C.red } });
  sl.addText("⚠  PERITONITIS = EMERGENT LAPAROTOMY — Do NOT wait for imaging when peritonism is present", {
    x: 0.3, y: 1.63, w: 9.4, h: 0.27,
    fontSize: 10.5, bold: true, color: C.white
  });

  steps.forEach((s, i) => {
    const x = (i % 3) * 3.2 + 0.25;
    const y = Math.floor(i / 3) * 1.55 + 1.98;
    sl.addShape(pres.ShapeType.rect, { x, y, w: 3.0, h: 1.42,
      fill: { color: "F8FAFC" }, line: { color: C.border, width: 0.8 } });
    sl.addShape(pres.ShapeType.ellipse, { x: x + 0.1, y: y + 0.08, w: 0.36, h: 0.36,
      fill: { color: C.navy }, line: { color: C.navy } });
    sl.addText(s.num, { x: x + 0.1, y: y + 0.08, w: 0.36, h: 0.36, fontSize: 11, bold: true, color: C.white, align: "center", valign: "middle" });
    sl.addText(s.head, { x: x + 0.5, y: y + 0.1, w: 2.45, h: 0.3, fontSize: 11, bold: true, color: C.navy });
    sl.addText(s.body, { x: x + 0.1, y: y + 0.44, w: 2.85, h: 0.94, fontSize: 10, color: C.darkText, wrap: true });
  });
}

// ─────────────────────────────────────────────
// 15. SURGICAL MANAGEMENT FLOWCHART
// ─────────────────────────────────────────────
{
  const sl = addSlide();
  sectionBanner(sl, "Section 7 — Management of AMI");
  slideTitle(sl, "Surgical Management — Open Surgery");

  // Two columns: Embolectomy and Bypass
  sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.6, w: 4.6, h: 0.36,
    fill: { color: C.red }, line: { color: C.red } });
  sl.addText("SMA EMBOLECTOMY (Embolic AMI — Gold Standard)", {
    x: 0.3, y: 1.61, w: 4.5, h: 0.33,
    fontSize: 10.5, bold: true, color: C.white
  });

  const embSteps = [
    "Midline laparotomy",
    "Colon reflected cephalad; small bowel to patient's right",
    "Expose SMA at base of transverse colon mesentery",
    "Intraoperative Doppler → localise loss of signal",
    "Transverse arteriotomy at SMA (reduces risk of stenosis vs. longitudinal)",
    "Fogarty balloon catheter embolectomy proximal + distal",
    "Completion angioscopy or on-table angiography",
    "Assess bowel viability (fluorescein + Doppler)",
    "Resect ONLY frankly necrotic bowel",
    "Temporary abdominal closure → Second-look 24–48 hrs"
  ];
  sl.addText(embSteps.map((t, i) => ({
    text: `${i + 1}. ${t}`,
    options: { fontSize: 10.8, color: C.darkText, bullet: false, breakLine: true, paraSpaceAfter: 3 }
  })), { x: 0.3, y: 2.0, w: 4.5, h: 3.35 });

  sl.addShape(pres.ShapeType.line, { x: 4.97, y: 1.6, w: 0, h: 3.8, line: { color: C.border, width: 0.8 } });

  sl.addShape(pres.ShapeType.rect, { x: 5.15, y: 1.6, w: 4.6, h: 0.36,
    fill: { color: C.navy }, line: { color: C.navy } });
  sl.addText("MESENTERIC BYPASS (Thrombotic AMI / CMI)", {
    x: 5.2, y: 1.61, w: 4.5, h: 0.33,
    fontSize: 10.5, bold: true, color: C.white
  });
  sl.addText([
    { text: "Antegrade Bypass (Supraceliac inflow):\n", options: { bold: true, fontSize: 11, color: C.teal, breakLine: true } },
    bullet("Inflow: supraceliac / distal thoracic aorta", 8),
    bullet("Bifurcated Dacron graft (12×6 or 14×7 cm) for celiac + SMA", 8),
    bullet("Less kinking; preferred in younger/fitter patients", 8),
    bullet("Transperitoneal: mobilise left liver lobe; divide left crus of diaphragm", 8),
    { text: "\nRetrograde Bypass (Infrarenal inflow):\n", options: { bold: true, fontSize: 11, color: C.orange, breakLine: true } },
    bullet("Inflow: infrarenal aorta or iliac artery", 8),
    bullet("PTFE or Dacron graft — C-loop or J-loop configuration to prevent kinking", 8),
    bullet("Preferred in emergency or when heavy supraceliac disease", 8),
    { text: "\nEndarterectomy:\n", options: { bold: true, fontSize: 11, color: C.green, breakLine: true } },
    bullet("Transaortic endarterectomy: trapdoor aortotomy; removes plaque", 8),
    bullet("Best for ostial lesions; requires aortic cross-clamp", 8),
  ], { x: 5.2, y: 2.0, w: 4.5, h: 3.35 });
}

// ─────────────────────────────────────────────
// 16. SECOND LOOK + BOWEL VIABILITY
// ─────────────────────────────────────────────
{
  const sl = addSlide();
  sectionBanner(sl, "Section 7 — Management of AMI");
  slideTitle(sl, "Second-Look Laparotomy & Bowel Viability Assessment");

  // Principle banner
  sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.62, w: 9.5, h: 0.32,
    fill: { color: C.teal }, line: { color: C.teal } });
  sl.addText("PRINCIPLE: Revascularize First → Resect ONLY Dead Bowel → Temp Closure → Second-Look 24–48 hrs → Definitive Closure", {
    x: 0.3, y: 1.63, w: 9.4, h: 0.29,
    fontSize: 10, bold: true, color: C.white
  });

  // Viability table
  const rows = [
    [
      { text: "Assessment Method", options: { bold: true, color: C.white, fill: { color: C.tableHdr } } },
      { text: "Viable Findings", options: { bold: true, color: C.white, fill: { color: "1E8449" } } },
      { text: "Non-Viable Findings", options: { bold: true, color: C.white, fill: { color: "C0392B" } } },
    ],
    ["Visual (colour)", "Pink / red, glistening serosa", "Black / green / grey, dull / mottled"],
    ["Peristalsis", "Present — good prognostic sign", "Absent"],
    ["Wall thickness & turgor", "Normal thickness, firm", "Thin (paper-thin) or oedematous"],
    ["Mesenteric pulse", "Palpable arterial pulsation", "Absent pulsation"],
    ["Intraop Doppler", "Audible Doppler signal at antimesenteric border", "Loss of signal = no flow"],
    ["IV Fluorescein + Wood's lamp", "Bright fluorescence under UV light", "No fluorescence = necrosis"],
    ["Subserosal haemorrhage", "Absent / minimal", "Extensive = concerning"],
  ];

  sl.addTable(rows, {
    x: 0.2, y: 2.0, w: 9.6, h: 3.35,
    colW: [2.4, 3.6, 3.6],
    border: { type: "solid", color: C.border, pt: 0.5 },
    fill: { color: C.tableAlt },
    rowH: 0.41,
    fontFace: "Calibri",
    fontSize: 11,
    color: C.darkText,
    align: "left",
    valign: "middle",
  });

  sl.addShape(pres.ShapeType.rect, { x: 0.2, y: 5.4, w: 9.6, h: 0.37,
    fill: { color: "FEF9E7" }, line: { color: C.orange, width: 1 } });
  sl.addText("Preserve ALL questionable bowel at first operation. Second-look allows recovery of marginal segments. < 100–150 cm small bowel remaining = Short Bowel Syndrome.", {
    x: 0.3, y: 5.43, w: 9.4, h: 0.32,
    fontSize: 10, color: C.orange
  });
}

// ─────────────────────────────────────────────
// 17. ENDOVASCULAR MANAGEMENT
// ─────────────────────────────────────────────
{
  const sl = addSlide();
  sectionBanner(sl, "Section 7 — Management");
  slideTitle(sl, "Endovascular Management — AMI & CMI");

  const rows = [
    [
      { text: "Technique", options: { bold: true, color: C.white, fill: { color: C.tableHdr } } },
      { text: "Indication", options: { bold: true, color: C.white, fill: { color: C.tableHdr } } },
      { text: "Key Points", options: { bold: true, color: C.white, fill: { color: C.tableHdr } } },
    ],
    [
      { text: "Percutaneous transluminal angioplasty (PTA)", options: {} },
      "CMI — short segment stenosis",
      "Balloon dilation; may need adjunct stent; restenosis ~30% without stent"
    ],
    [
      { text: "Primary Stenting", options: {} },
      "CMI first-line / AMI without peritonitis",
      "Balloon-expandable COVERED stent preferred; traps plaque, prevents embolism"
    ],
    [
      { text: "Intra-arterial thrombolysis", options: {} },
      "Acute thrombosis / embolism (no peritonitis)",
      "Papaverine or tPA; allows simultaneous diagnostic angiography; cannot assess bowel viability"
    ],
    [
      { text: "Pharmaco-mechanical embolectomy", options: {} },
      "Embolic AMI — early, no peritonitis",
      "Aspiration + thrombolytics; hybrid with open if needed"
    ],
    [
      { text: "Intraarterial vasodilators (NOMI)", options: {} },
      "NOMI — no peritonitis",
      "Papaverine infusion 30–60 mg/hr into SMA; most studied. Alternatively nitroglycerin / prostaglandins"
    ],
  ];

  sl.addTable(rows, {
    x: 0.2, y: 1.6, w: 9.6, h: 3.7,
    colW: [2.6, 2.8, 4.2],
    border: { type: "solid", color: C.border, pt: 0.5 },
    fill: { color: C.tableAlt },
    rowH: 0.6,
    fontFace: "Calibri",
    fontSize: 11,
    color: C.darkText,
    align: "left",
    valign: "middle",
  });

  // Access technique note
  sl.addShape(pres.ShapeType.rect, { x: 0.2, y: 5.37, w: 9.6, h: 0.42,
    fill: { color: "EBF5FB" }, line: { color: C.teal, width: 1 } });
  sl.addText("Access: Femoral or brachial approach · Selective angled catheters · Systemic heparin after access · Balloon diameter = reference vessel diameter · Post-procedure antiplatelet ≥ 6 months", {
    x: 0.3, y: 5.4, w: 9.4, h: 0.36,
    fontSize: 10, color: C.teal
  });
}

// ─────────────────────────────────────────────
// 18. CMI — WORKUP & REVASCULARIZATION TABLE
// ─────────────────────────────────────────────
{
  const sl = addSlide();
  sectionBanner(sl, "Section 8 — Chronic Mesenteric Ischemia");
  slideTitle(sl, "Chronic Mesenteric Ischemia — Workup & Revascularization");

  sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.62, w: 9.5, h: 0.3,
    fill: { color: "EBF5FB" }, line: { color: C.teal, width: 1 } });
  sl.addText("Requires ≥ 2 of 3 vessels (Celiac, SMA, IMA) with significant stenosis/occlusion for symptoms. Atherosclerosis is the most common aetiology.", {
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    fontSize: 10.5, color: C.navy, italic: true
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  const rows = [
    [
      { text: "CMI Assessment Step", options: { bold: true, color: C.white, fill: { color: C.tableHdr } } },
      { text: "Details", options: { bold: true, color: C.white, fill: { color: C.tableHdr } } },
    ],
    [{ text: "Clinical criteria", options: { bold: true } }, "Classic triad: postprandial pain + food fear + weight loss; r/o malignancy first"],
    [{ text: "Duplex US", options: { bold: true } }, "SMA PSV >275 cm/s; EDV >45 cm/s = >70% stenosis. Sensitivity 92%, Specificity 96%"],
    [{ text: "CT/MR Angiography", options: { bold: true } }, "Defines anatomy, collaterals, degree of stenosis; plan revascularisation"],
    [{ text: "Endovascular (1st line)", options: { bold: true } }, "Balloon-expandable COVERED stent; 70–80% of CMI procedures; primary patency 75–80% at 3 yrs"],
    [{ text: "Open bypass — Antegrade", options: { bold: true } }, "Supraceliac inflow; bifurcated Dacron; preferred in younger/fitter; superior long-term patency"],
    [{ text: "Open bypass — Retrograde", options: { bold: true } }, "Infrarenal/iliac inflow; C or J-loop graft; preferred in elderly/high risk"],
    [{ text: "Transaortic endarterectomy", options: { bold: true } }, "Best for ostial/flush lesions; trapdoor aortotomy; multi-vessel simultaneous treatment"],
    [{ text: "Post-procedure care", options: { bold: true } }, "Oral feed when symptoms allow; nutrition rehab; duplex surveillance at 1, 6, 12 months then annually"],
  ];

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    valign: "middle",
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}

// ─────────────────────────────────────────────
// 19. OUTCOMES & SPECIAL SCENARIOS
// ─────────────────────────────────────────────
{
  const sl = addSlide();
  sectionBanner(sl, "Section 9 — Outcomes & Special Scenarios");
  slideTitle(sl, "Outcomes Summary & Special Scenarios");

  // Outcomes grid
  const outcomes = [
    { label: "Overall AMI Mortality", val: "17–21%", color: C.red },
    { label: "Thrombotic (untreated)", val: "77%", color: "7B241C" },
    { label: "Embolic (untreated)", val: "54%", color: C.red },
    { label: "Open Repair (2010)", val: "33%", color: C.orange },
    { label: "Endovascular (2010)", val: "15%", color: C.green },
    { label: "ICU-admitted AMI", val: "> 70%", color: "7B241C" },
  ];

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    sl.addText(o.label, { x, y: y + 0.48, w: 3.0, h: 0.32, fontSize: 9.5, color: C.white, align: "center" });
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  // Special scenarios
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    fontSize: 11, bold: true, color: C.white
  });

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      { text: "Scenario", options: { bold: true, color: C.white, fill: { color: C.tableHdr } } },
      { text: "Key Management Points", options: { bold: true, color: C.white, fill: { color: C.tableHdr } } },
    ],
    ["Spontaneous SMA Dissection (SISMAD)", "Rare; males, East Asian. Asymptomatic → antiplatelet. Mild → anticoagulation. Persistent pain/aneurysm → endovascular stenting."],
    ["Post-aortic surgery ischaemic colitis", "Ligation of IMA during aortic repair; sigmoid most at risk. Monitor postop. Flexible sigmoidoscopy if suspected."],
    ["Short Bowel Syndrome", "< 100–150 cm small bowel = lifelong TPN dependency. Prevention: revascularise first, preserve marginal segments, second-look."],
    ["Median Arcuate Ligament Syndrome", "Extrinsic celiac compression by diaphragmatic crus. Treatment: ligament division ± celiac reconstruction."],
  ];

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}

// ─────────────────────────────────────────────
// 20. KEY TAKE-AWAYS / CLOSING SLIDE
// ─────────────────────────────────────────────
{
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    { num: "02", text: "No laboratory test can exclude AMI. CT angiography (biphasic) is the gold standard — specificity > 97% for key findings." },
    { num: "03", text: "PERITONITIS = Emergent laparotomy. Do NOT delay for imaging when peritonism is present." },
    { num: "04", text: "Revascularise FIRST — resect only clearly dead bowel. Preserve questionable segments for second-look at 24–48 hours." },
    { num: "05", text: "NOMI: treat the underlying cause + intraarterial vasodilators. MVT: anticoagulate. Tailor treatment to subtype." },
    { num: "06", text: "CMI: Endovascular (covered stent) is first-line for most; open bypass for younger/fitter patients with superior long-term durability." },
  ];

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  sl.addText("Based on: Schwartz's Principles of Surgery 11e  ·  Sabiston Textbook of Surgery  ·  Current Surgical Therapy 14e  ·  2026", {
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    fontSize: 9, color: "5A7A9A", align: "center"
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}

// ─────────────────────────────────────────────
// WRITE FILE
// ─────────────────────────────────────────────
const outPath = "/home/daytona/workspace/mesenteric-ischemia/Mesenteric_Ischemia_Merged.pptx";
pres.writeFile({ fileName: outPath })
  .then(() => console.log("SUCCESS: " + outPath))
  .catch(e => { console.error("ERROR:", e); process.exit(1); });

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/mesenteric-ischemia/build.js'