fistula management treatment outcomes

fistula anatomy types treatment clinical images medical

PMID: 38050857

PMID: 37460830

PMID: 38441138

PMID: 37207318

PMID: 39332865

mkdir -p /home/daytona/workspace/fistula-ppt && ls /home/daytona/workspace/fistu…

~/fistula-ppt/create_ppt.js

const pptxgen = require("pptxgenjs");
const { execSync } = require("child_process");

// ─── Fetch images ────────────────────────────────────────────────────────────
const imageUrls = [
  "https://upload.wikimedia.org/wikipedia/commons/thumb/3/3e/Anal_fistula_scheme.svg/640px-Anal_fistula_scheme.svg.png",
  "https://upload.wikimedia.org/wikipedia/commons/thumb/f/f9/Anorectal_abscess.svg/400px-Anorectal_abscess.svg.png",
  "https://upload.wikimedia.org/wikipedia/commons/thumb/0/02/Tracheoesophageal_fistula.svg/400px-Tracheoesophageal_fistula.svg.png",
  "https://upload.wikimedia.org/wikipedia/commons/thumb/3/3e/Anal_fistula_scheme.svg/640px-Anal_fistula_scheme.svg.png"
];

let images = [];
try {
  const raw = execSync(
    `node /home/daytona/skills/shared/scripts/fetch_images.js "${imageUrls[0]}" "${imageUrls[1]}" "${imageUrls[2]}"`,
    { timeout: 30000 }
  ).toString();
  images = JSON.parse(raw);
} catch (e) {
  console.error("Image fetch failed:", e.message);
  images = [];
}

// ─── Color palette ───────────────────────────────────────────────────────────
const DARK_NAVY   = "0D2137";
const MED_BLUE    = "1A4B7A";
const TEAL        = "1B9AAA";
const LIGHT_BG    = "F0F4F8";
const WHITE       = "FFFFFF";
const ACCENT_GOLD = "F4A261";
const BODY_DARK   = "1C2B3A";
const SUBTEXT     = "4A6278";

// ─── Helpers ─────────────────────────────────────────────────────────────────
function darkSlide(pres) {
  let s = pres.addSlide();
  s.background = { color: DARK_NAVY };
  return s;
}
function lightSlide(pres) {
  let s = pres.addSlide();
  s.background = { color: LIGHT_BG };
  return s;
}
function addTopStripe(slide, color) {
  slide.addShape("rect", { x: 0, y: 0, w: 10, h: 0.08, fill: { color: color || TEAL } });
}
function addBottomStripe(slide) {
  slide.addShape("rect", { x: 0, y: 5.545, w: 10, h: 0.08, fill: { color: TEAL } });
}
function sectionHeader(slide, num, label) {
  slide.addShape("rect", { x: 0, y: 0, w: 0.45, h: 5.625, fill: { color: MED_BLUE } });
  slide.addText(label.toUpperCase(), {
    x: 0.05, y: 1.5, w: 0.35, h: 2.5, fontSize: 8, color: WHITE, bold: true,
    rotate: 270, align: "center"
  });
}
function paperLabel(slide, paper) {
  slide.addShape("rect", { x: 0, y: 5.3, w: 10, h: 0.325, fill: { color: MED_BLUE } });
  slide.addText(paper, {
    x: 0.3, y: 5.3, w: 9.4, h: 0.325, fontSize: 7.5, color: "BBCCDD", italic: true,
    align: "left", valign: "middle"
  });
}

// ─── Presentation ────────────────────────────────────────────────────────────
let pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title  = "Fistula – Recent Research Review";
pres.author = "Research Group";

// ═══════════════════════════════════════════════
// SLIDE 1 – Title
// ═══════════════════════════════════════════════
{
  let s = darkSlide(pres);
  addTopStripe(s, TEAL);
  addBottomStripe(s);

  // decorative accent rectangle
  s.addShape("rect", { x: 0.5, y: 1.6, w: 0.06, h: 1.5, fill: { color: ACCENT_GOLD } });

  s.addText("FISTULA", {
    x: 0.75, y: 0.75, w: 8.5, h: 0.85,
    fontSize: 48, bold: true, color: WHITE, fontFace: "Calibri", charSpacing: 6
  });
  s.addText("A Review of Recent Research", {
    x: 0.75, y: 1.65, w: 7, h: 0.6,
    fontSize: 22, color: TEAL, fontFace: "Calibri"
  });
  s.addText("5 Key Papers | 2023–2024", {
    x: 0.75, y: 2.35, w: 5, h: 0.4,
    fontSize: 14, color: "8AADCC", fontFace: "Calibri"
  });

  // decorative circles
  s.addShape("ellipse", { x: 7.8, y: 1.0, w: 2.2, h: 2.2, fill: { color: "112840" }, line: { color: TEAL, pt: 1.5 } });
  s.addShape("ellipse", { x: 8.2, y: 1.6, w: 1.4, h: 1.4, fill: { color: TEAL }, line: { color: WHITE, pt: 0.5 } });

  s.addText("Topics: Anal Fistula • Crohn's Disease • Enterocutaneous Fistula • Tracheoesophageal Fistula", {
    x: 0.5, y: 4.5, w: 9, h: 0.55,
    fontSize: 11, color: "5A8AAA", italic: true, align: "left"
  });
  s.addText("Prepared: July 2026", {
    x: 7.5, y: 5.1, w: 2.2, h: 0.3, fontSize: 9, color: "456070", align: "right"
  });
}

// ═══════════════════════════════════════════════
// SLIDE 2 – Overview / Table of Papers
// ═══════════════════════════════════════════════
{
  let s = lightSlide(pres);
  addTopStripe(s, MED_BLUE);
  addBottomStripe(s);

  s.addText("Overview: 5 Research Papers", {
    x: 0.4, y: 0.18, w: 9.2, h: 0.55,
    fontSize: 22, bold: true, color: MED_BLUE, fontFace: "Calibri"
  });

  const rows = [
    [
      { text: "#",        options: { bold: true } },
      { text: "Title (Short)",  options: { bold: true } },
      { text: "Authors",  options: { bold: true } },
      { text: "Year",     options: { bold: true } },
      { text: "Type",     options: { bold: true } },
    ],
    ["1", "ESCP Guidelines – Cryptoglandular Anal Fistula",          "Reza et al.",    "2024", "Meta-Analysis / Guideline"],
    ["2", "Surgical Treatments for Anal Fistula – Network Meta-Analysis", "Bhat et al.", "2023", "Network Meta-Analysis"],
    ["3", "Current Enterocutaneous Fistula Management",              "Vanzant et al.", "2024", "Review"],
    ["4", "Management of Perianal Crohn's Disease",                  "Parian et al.",  "2023", "Review"],
    ["5", "Airway Esophageal (Tracheoesophageal) Fistula",           "Koch et al.",    "2024", "Review"],
  ];

  s.addTable(rows, {
    x: 0.4, y: 0.9, w: 9.2,
    colW: [0.35, 4.2, 1.8, 0.7, 2.15],
    fontSize: 10,
    fontFace: "Calibri",
    border: { type: "solid", color: "C5D5E8", pt: 0.5 },
    fill: "FFFFFF",
    align: "left",
    valign: "middle",
    rowH: 0.5,
    autoPage: false,
    color: BODY_DARK,
    headFill: { color: MED_BLUE },
    headColor: WHITE,
    headFontSize: 11,
  });

  s.addText("All papers retrieved from PubMed | Evidence-based, peer-reviewed", {
    x: 0.4, y: 5.25, w: 9.2, h: 0.3,
    fontSize: 8.5, color: SUBTEXT, italic: true
  });
}

// ═══════════════════════════════════════════════
// SLIDE 3 – What is a Fistula? (Background)
// ═══════════════════════════════════════════════
{
  let s = lightSlide(pres);
  addTopStripe(s, TEAL);
  s.addShape("rect", { x: 0, y: 0, w: 4.2, h: 5.625, fill: { color: "D8E8F2" } });
  addBottomStripe(s);

  s.addText("Background: What is a Fistula?", {
    x: 4.4, y: 0.2, w: 5.4, h: 0.55,
    fontSize: 20, bold: true, color: MED_BLUE
  });

  const bullets = [
    "An abnormal connection between two epithelialised surfaces or hollow organs",
    "Common types: Anal/perianal, Enterocutaneous, Rectovaginal, Tracheoesophageal",
    "Causes: cryptoglandular infection, Crohn's disease, trauma, post-surgical, malignancy",
    "Classification (Parks): intersphincteric, transsphincteric, suprasphincteric, extrasphincteric",
    "Key complications: sepsis, malnutrition, incontinence, poor quality of life",
    "Management requires multidisciplinary teams: surgery, gastroenterology, nutrition, wound care",
  ];

  const bulletItems = bullets.map((b, i) => ({
    text: b,
    options: { bullet: { code: "25CF", color: TEAL, size: 70 }, breakLine: i < bullets.length - 1, paraSpaceAfter: 4 }
  }));

  s.addText(bulletItems, {
    x: 4.4, y: 0.9, w: 5.3, h: 4.4,
    fontSize: 11.5, color: BODY_DARK, fontFace: "Calibri", valign: "top"
  });

  // Left panel: image + label
  if (images[0] && !images[0].error) {
    s.addImage({ data: images[0].base64, x: 0.15, y: 0.55, w: 3.85, h: 3.5 });
  } else {
    s.addShape("rect", { x: 0.15, y: 0.55, w: 3.85, h: 3.5, fill: { color: "B0C8DC" } });
    s.addText("Anal Fistula Anatomy\n(Diagram)", {
      x: 0.2, y: 1.8, w: 3.75, h: 1.0, fontSize: 12, color: MED_BLUE, align: "center", bold: true
    });
  }

  s.addShape("rect", { x: 0.15, y: 4.1, w: 3.85, h: 0.6, fill: { color: MED_BLUE } });
  s.addText("Parks Classification of Anal Fistula", {
    x: 0.2, y: 4.1, w: 3.75, h: 0.6, fontSize: 9.5, color: WHITE, align: "center", bold: true, valign: "middle"
  });
}

// ═══════════════════════════════════════════════
// SLIDE 4 – Paper 1: ESCP Guidelines
// ═══════════════════════════════════════════════
{
  let s = lightSlide(pres);
  addTopStripe(s, ACCENT_GOLD);
  sectionHeader(s, 1, "Paper 1");
  addBottomStripe(s);

  s.addShape("rect", { x: 0.45, y: 0.08, w: 9.55, h: 0.78, fill: { color: MED_BLUE } });
  s.addText("Paper 1: ESCP Guidelines for Cryptoglandular Anal Fistula", {
    x: 0.55, y: 0.08, w: 9.3, h: 0.78,
    fontSize: 16, bold: true, color: WHITE, valign: "middle"
  });

  s.addText("Reza et al. | Colorectal Disease | 2024 | PMID: 38050857", {
    x: 0.55, y: 0.95, w: 9, h: 0.3,
    fontSize: 10, color: SUBTEXT, italic: true
  });

  const findings = [
    ["Scope", "42 evidence-based recommendations across 7 sections on perianal abscess & anal fistula"],
    ["Diagnosis", "MRI is the gold standard for preoperative fistula mapping; EUA remains essential for staging"],
    ["Simple Fistulas", "Fistulotomy recommended for low intersphincteric/transsphincteric fistulas; low recurrence"],
    ["Complex Fistulas", "Sphincter-preserving techniques (LIFT, flaps, plugs) preferred to protect continence"],
    ["Outcomes", "Critical outcomes tracked: fistula healing, recurrence rate, and bowel incontinence"],
    ["Methodology", "GDG of 21 coloproctologists using AGREE-S toolkit; GRADE methodology for recommendations"],
  ];

  findings.forEach(([label, text], i) => {
    const yPos = 1.35 + i * 0.66;
    s.addShape("rect", { x: 0.55, y: yPos, w: 2.0, h: 0.5, fill: { color: TEAL }, rectRadius: 0.05 });
    s.addText(label, {
      x: 0.55, y: yPos, w: 2.0, h: 0.5,
      fontSize: 10, bold: true, color: WHITE, align: "center", valign: "middle"
    });
    s.addText(text, {
      x: 2.7, y: yPos, w: 6.9, h: 0.5,
      fontSize: 10.5, color: BODY_DARK, valign: "middle"
    });
  });

  paperLabel(s, "Reza L et al. European Society of Coloproctology Guidelines. Colorectal Dis. 2024. doi: 10.1111/codi.16741");
}

// ═══════════════════════════════════════════════
// SLIDE 5 – Paper 2: Network Meta-Analysis
// ═══════════════════════════════════════════════
{
  let s = lightSlide(pres);
  addTopStripe(s, TEAL);
  sectionHeader(s, 2, "Paper 2");
  addBottomStripe(s);

  s.addShape("rect", { x: 0.45, y: 0.08, w: 9.55, h: 0.78, fill: { color: "15607A" } });
  s.addText("Paper 2: Surgical Treatments for Anal Fistula – Network Meta-Analysis", {
    x: 0.55, y: 0.08, w: 9.3, h: 0.78,
    fontSize: 15, bold: true, color: WHITE, valign: "middle"
  });
  s.addText("Bhat et al. | Techniques in Coloproctology | 2023 | PMID: 37460830", {
    x: 0.55, y: 0.95, w: 9, h: 0.3, fontSize: 10, color: SUBTEXT, italic: true
  });

  // Two-column layout
  const leftPoints = [
    "52 RCTs included; 14 surgical treatments compared",
    "Classified as simple vs complex anal fistula",
    "No treatment showed significant superiority in healing rates",
    "Short-term & long-term success rates were statistically comparable",
  ];
  const rightPoints = [
    "LIFT ranked best for minimising incontinence in both simple (99.1%) and complex fistulas (86.2%)",
    "Fistulotomy effective for simple cases but risks continence",
    "Need for better-designed, larger RCTs highlighted",
    "Conclusion: LIFT = best continence-preserving option",
  ];

  s.addShape("rect", { x: 0.55, y: 1.3, w: 4.3, h: 0.38, fill: { color: MED_BLUE } });
  s.addText("Key Findings", { x: 0.55, y: 1.3, w: 4.3, h: 0.38, fontSize: 11, bold: true, color: WHITE, align: "center", valign: "middle" });

  s.addShape("rect", { x: 5.1, y: 1.3, w: 4.5, h: 0.38, fill: { color: ACCENT_GOLD } });
  s.addText("Clinical Implications", { x: 5.1, y: 1.3, w: 4.5, h: 0.38, fontSize: 11, bold: true, color: DARK_NAVY, align: "center", valign: "middle" });

  leftPoints.forEach((p, i) => {
    s.addText([{ text: p, options: { bullet: true, breakLine: false } }], {
      x: 0.55, y: 1.78 + i * 0.72, w: 4.3, h: 0.6,
      fontSize: 11, color: BODY_DARK, valign: "top"
    });
  });
  rightPoints.forEach((p, i) => {
    s.addText([{ text: p, options: { bullet: true, breakLine: false } }], {
      x: 5.1, y: 1.78 + i * 0.72, w: 4.5, h: 0.6,
      fontSize: 11, color: BODY_DARK, valign: "top"
    });
  });

  // Highlight box
  s.addShape("rect", { x: 0.55, y: 4.8, w: 9.05, h: 0.42, fill: { color: "E8F4F7" }, line: { color: TEAL, pt: 1 } });
  s.addText("Key Takeaway: LIFT procedure associated with least bowel incontinence regardless of fistula complexity", {
    x: 0.65, y: 4.8, w: 8.85, h: 0.42,
    fontSize: 10.5, color: MED_BLUE, bold: true, valign: "middle"
  });

  paperLabel(s, "Bhat S et al. Efficacy of different surgical treatments for anal fistula: network meta-analysis. Tech Coloproctol. 2023. doi: 10.1007/s10151-023-02845-8");
}

// ═══════════════════════════════════════════════
// SLIDE 6 – Paper 3: Enterocutaneous Fistula
// ═══════════════════════════════════════════════
{
  let s = lightSlide(pres);
  addTopStripe(s, ACCENT_GOLD);
  sectionHeader(s, 3, "Paper 3");
  addBottomStripe(s);

  s.addShape("rect", { x: 0.45, y: 0.08, w: 9.55, h: 0.78, fill: { color: "8B4513" } });
  s.addText("Paper 3: Current Enterocutaneous Fistula (ECF) Management", {
    x: 0.55, y: 0.08, w: 9.3, h: 0.78,
    fontSize: 16, bold: true, color: WHITE, valign: "middle"
  });
  s.addText("Vanzant et al. | Curr Opin Crit Care | 2024 | PMID: 38441138", {
    x: 0.55, y: 0.95, w: 9, h: 0.3, fontSize: 10, color: SUBTEXT, italic: true
  });

  const steps = [
    { icon: "1", title: "Source Control", text: "Drainage of infection, control of fistula output, wound care optimization" },
    { icon: "2", title: "Nutrition",       text: "Trend toward enteral nutrition over TPN; improved fistuloclysis devices" },
    { icon: "3", title: "Wound Care",      text: "Wound vacuum devices, pouching systems, absorptive dressings" },
    { icon: "4", title: "Prehabilitation", text: "Preoperative optimization of patient fitness to improve surgical outcomes" },
    { icon: "5", title: "MDT Approach",    text: "Surgeon, dietitian, wound care nurse, intensivist collaboration required" },
  ];

  steps.forEach((step, i) => {
    const yPos = 1.3 + i * 0.8;
    // Number circle
    s.addShape("ellipse", { x: 0.55, y: yPos + 0.1, w: 0.55, h: 0.55, fill: { color: TEAL } });
    s.addText(step.icon, { x: 0.55, y: yPos + 0.1, w: 0.55, h: 0.55, fontSize: 14, bold: true, color: WHITE, align: "center", valign: "middle" });
    // Title
    s.addText(step.title, { x: 1.25, y: yPos + 0.05, w: 2.2, h: 0.55, fontSize: 12, bold: true, color: MED_BLUE, valign: "middle" });
    // Text
    s.addText(step.text, { x: 3.55, y: yPos + 0.05, w: 6.05, h: 0.55, fontSize: 11, color: BODY_DARK, valign: "middle" });
    if (i < steps.length - 1)
      s.addShape("line", { x: 0.55, y: yPos + 0.65, w: 9.05, h: 0, line: { color: "D0DCE8", pt: 0.5 } });
  });

  paperLabel(s, "Vanzant E et al. Current fistula management. Curr Opin Crit Care. 2024. doi: 10.1097/MCC.0000000000001147");
}

// ═══════════════════════════════════════════════
// SLIDE 7 – Paper 4: Perianal Crohn's Disease
// ═══════════════════════════════════════════════
{
  let s = lightSlide(pres);
  addTopStripe(s, MED_BLUE);
  sectionHeader(s, 4, "Paper 4");
  addBottomStripe(s);

  s.addShape("rect", { x: 0.45, y: 0.08, w: 9.55, h: 0.78, fill: { color: "1A3A5C" } });
  s.addText("Paper 4: Management of Perianal Crohn's Disease", {
    x: 0.55, y: 0.08, w: 9.3, h: 0.78,
    fontSize: 16, bold: true, color: WHITE, valign: "middle"
  });
  s.addText("Parian et al. | Am J Gastroenterol | 2023 | PMID: 37207318", {
    x: 0.55, y: 0.95, w: 9, h: 0.3, fontSize: 10, color: SUBTEXT, italic: true
  });

  // Two boxes: Medical & Surgical
  s.addShape("rect", { x: 0.55, y: 1.35, w: 4.3, h: 3.8, fill: { color: "E3EEF8" }, line: { color: MED_BLUE, pt: 1 } });
  s.addShape("rect", { x: 5.1, y: 1.35, w: 4.5, h: 3.8, fill: { color: "FFF3E0" }, line: { color: ACCENT_GOLD, pt: 1 } });

  s.addShape("rect", { x: 0.55, y: 1.35, w: 4.3, h: 0.45, fill: { color: MED_BLUE } });
  s.addText("Medical Management", { x: 0.55, y: 1.35, w: 4.3, h: 0.45, fontSize: 12, bold: true, color: WHITE, align: "center", valign: "middle" });

  s.addShape("rect", { x: 5.1, y: 1.35, w: 4.5, h: 0.45, fill: { color: ACCENT_GOLD } });
  s.addText("Surgical Management", { x: 5.1, y: 1.35, w: 4.5, h: 0.45, fontSize: 12, bold: true, color: DARK_NAVY, align: "center", valign: "middle" });

  const medItems = [
    "Biologics (anti-TNF: infliximab, adalimumab) – first-line",
    "Dual therapy with thiopurines",
    "Therapeutic drug monitoring",
    "Stem cell therapy – emerging promising treatment (darvadstrocel)",
    "Treat luminal & fistula inflammation simultaneously",
  ];
  const surgItems = [
    "Drain abscesses BEFORE immunosuppression",
    "Seton placement for complex tracts",
    "Fistulotomy for simple low tracts",
    "Advancement flap & LIFT once inflammation controlled",
    "Proctectomy reserved for refractory disease",
  ];

  const medBullets = medItems.map((t, i) => ({ text: t, options: { bullet: true, breakLine: i < medItems.length-1, paraSpaceAfter: 3 } }));
  const surgBullets = surgItems.map((t, i) => ({ text: t, options: { bullet: true, breakLine: i < surgItems.length-1, paraSpaceAfter: 3 } }));

  s.addText(medBullets, { x: 0.65, y: 1.9, w: 4.1, h: 3.1, fontSize: 10.5, color: BODY_DARK, valign: "top" });
  s.addText(surgBullets, { x: 5.2, y: 1.9, w: 4.3, h: 3.1, fontSize: 10.5, color: BODY_DARK, valign: "top" });

  s.addText("Affects 25–35% of Crohn's disease patients; significant impact on quality of life & healthcare costs", {
    x: 0.55, y: 5.17, w: 9.1, h: 0.3, fontSize: 9, color: SUBTEXT, italic: true
  });
  paperLabel(s, "Parian AM et al. Management of Perianal Crohn's Disease. Am J Gastroenterol. 2023. doi: 10.14309/ajg.0000000000002326");
}

// ═══════════════════════════════════════════════
// SLIDE 8 – Paper 5: Tracheoesophageal Fistula
// ═══════════════════════════════════════════════
{
  let s = lightSlide(pres);
  addTopStripe(s, TEAL);
  s.addShape("rect", { x: 0, y: 0, w: 4.5, h: 5.625, fill: { color: "D8EEF3" } });
  addBottomStripe(s);

  s.addShape("rect", { x: 0, y: 0.08, w: 4.5, h: 0.78, fill: { color: TEAL } });
  s.addText("Paper 5", { x: 0.1, y: 0.08, w: 4.3, h: 0.78, fontSize: 14, bold: true, color: WHITE, valign: "middle", align: "center" });

  s.addText("Airway Esophageal (Tracheoesophageal) Fistula", {
    x: 4.7, y: 0.1, w: 5.1, h: 0.75, fontSize: 15, bold: true, color: MED_BLUE
  });
  s.addText("Koch et al. | Thorac Surg Clin | 2024 | PMID: 39332865", {
    x: 4.7, y: 0.9, w: 5.0, h: 0.28, fontSize: 9.5, color: SUBTEXT, italic: true
  });

  const rightPoints = [
    { label: "Definition", text: "Abnormal pathologic connection between trachea & esophagus – rare but life-threatening" },
    { label: "Causes",     text: "Malignancy (most common), prolonged intubation, trauma, post-surgical, congenital" },
    { label: "Endoscopic", text: "Tracheal & esophageal stenting increasingly used; effective bridge to surgery" },
    { label: "Surgery",    text: "Definitive: fistula division, closure of tracts, interposed muscle flap to prevent recurrence" },
    { label: "Advances",   text: "Improved diagnostics, endoscopic techniques & ICU care – significantly better outcomes" },
  ];

  rightPoints.forEach((pt, i) => {
    s.addShape("rect", { x: 4.7, y: 1.3 + i * 0.76, w: 1.4, h: 0.55, fill: { color: TEAL } });
    s.addText(pt.label, { x: 4.7, y: 1.3 + i * 0.76, w: 1.4, h: 0.55, fontSize: 9.5, bold: true, color: WHITE, align: "center", valign: "middle" });
    s.addText(pt.text, { x: 6.25, y: 1.3 + i * 0.76, w: 3.55, h: 0.55, fontSize: 10, color: BODY_DARK, valign: "middle" });
  });

  // TEF image on left panel
  if (images[2] && !images[2].error) {
    s.addImage({ data: images[2].base64, x: 0.2, y: 1.05, w: 4.1, h: 3.5 });
  } else {
    s.addShape("rect", { x: 0.2, y: 1.1, w: 4.1, h: 3.3, fill: { color: "A8D8E8" } });
    s.addText("Tracheoesophageal\nFistula", {
      x: 0.2, y: 2.2, w: 4.1, h: 1.1, fontSize: 13, color: MED_BLUE, align: "center", bold: true
    });
  }
  s.addShape("rect", { x: 0.2, y: 4.45, w: 4.1, h: 0.55, fill: { color: MED_BLUE } });
  s.addText("Tracheoesophageal Fistula (TEF) Anatomy", {
    x: 0.2, y: 4.45, w: 4.1, h: 0.55, fontSize: 9, color: WHITE, align: "center", bold: true, valign: "middle"
  });

  paperLabel(s, "Koch KE et al. Airway Esophageal Fistula. Thorac Surg Clin. 2024. doi: 10.1016/j.thorsurg.2024.07.005");
}

// ═══════════════════════════════════════════════
// SLIDE 9 – Comparative Summary / Key Themes
// ═══════════════════════════════════════════════
{
  let s = lightSlide(pres);
  addTopStripe(s, MED_BLUE);
  addBottomStripe(s);

  s.addText("Comparative Summary: Key Themes Across All 5 Papers", {
    x: 0.4, y: 0.12, w: 9.2, h: 0.6, fontSize: 18, bold: true, color: MED_BLUE
  });

  const themes = [
    {
      title: "Multidisciplinary Care",
      color: MED_BLUE,
      text: "All 5 papers emphasize need for MDT\n(surgeon, GI, nutritionist, wound care)"
    },
    {
      title: "Sphincter Preservation",
      color: TEAL,
      text: "LIFT ranked highest for continence;\npreservation critical in complex fistulas"
    },
    {
      title: "Imaging & Diagnosis",
      color: "5A4FB2",
      text: "MRI gold standard; 98% accuracy\nin fistula tract delineation"
    },
    {
      title: "Emerging Therapies",
      color: "B5451B",
      text: "Stem cells (Crohn's), enteral nutrition,\nendoscopic stenting (TEF)"
    },
    {
      title: "Nutritional Optimization",
      color: "2E7D32",
      text: "ECF: enteral nutrition over TPN;\nprehabilitation improves surgical outcomes"
    },
  ];

  themes.forEach((t, i) => {
    const col = i % 3;
    const row = Math.floor(i / 3);
    const x = 0.4 + col * 3.15;
    const y = 0.9 + row * 2.2;
    const w = 2.95;
    const h = 2.0;

    s.addShape("rect", { x, y, w, h, fill: { color: WHITE }, line: { color: t.color, pt: 2 }, rectRadius: 0.1 });
    s.addShape("rect", { x, y, w, h: 0.5, fill: { color: t.color }, rectRadius: 0.08 });
    s.addText(t.title, { x, y, w, h: 0.5, fontSize: 11, bold: true, color: WHITE, align: "center", valign: "middle" });
    s.addText(t.text, { x: x + 0.1, y: y + 0.6, w: w - 0.2, h: 1.3, fontSize: 11, color: BODY_DARK, align: "center", valign: "middle" });
  });

  s.addText("Cross-cutting Finding: No single surgical technique is universally superior — patient-specific anatomy and pathology must guide selection", {
    x: 0.4, y: 5.2, w: 9.2, h: 0.3, fontSize: 9.5, color: SUBTEXT, italic: true
  });
}

// ═══════════════════════════════════════════════
// SLIDE 10 – Conclusions & References
// ═══════════════════════════════════════════════
{
  let s = darkSlide(pres);
  addTopStripe(s, TEAL);

  s.addText("Conclusions & References", {
    x: 0.5, y: 0.15, w: 9, h: 0.6,
    fontSize: 22, bold: true, color: WHITE
  });

  s.addShape("line", { x: 0.5, y: 0.8, w: 9, h: 0, line: { color: TEAL, pt: 1.5 } });

  const conclusions = [
    "ESCP 2024 guidelines provide 42 evidence-based recommendations for cryptoglandular anal fistula management",
    "LIFT procedure consistently associated with lowest incontinence rates across surgical options (Bhat et al., 2023)",
    "ECF management is evolving toward enteral nutrition, fistuloclysis, and structured prehabilitation protocols",
    "Perianal Crohn's fistulas require combined biological therapy + staged surgical intervention for best outcomes",
    "Tracheoesophageal fistulas benefit from endoscopic stenting as bridge to definitive surgical repair",
  ];

  conclusions.forEach((c, i) => {
    s.addShape("rect", { x: 0.5, y: 0.9 + i * 0.57, w: 0.35, h: 0.4, fill: { color: TEAL }, rectRadius: 0.04 });
    s.addText(`${i+1}`, { x: 0.5, y: 0.9 + i * 0.57, w: 0.35, h: 0.4, fontSize: 12, bold: true, color: WHITE, align: "center", valign: "middle" });
    s.addText(c, { x: 1.0, y: 0.9 + i * 0.57, w: 8.7, h: 0.42, fontSize: 11, color: "CCDDE8", valign: "middle" });
  });

  s.addShape("rect", { x: 0.5, y: 3.85, w: 9, h: 0.05, fill: { color: TEAL } });

  s.addText("References", { x: 0.5, y: 3.98, w: 9, h: 0.38, fontSize: 13, bold: true, color: ACCENT_GOLD });

  const refs = [
    "1. Reza L et al. ESCP Guidelines for cryptoglandular anal fistula. Colorectal Dis. 2024. PMID: 38050857",
    "2. Bhat S et al. Efficacy of surgical treatments for anal fistula: network meta-analysis. Tech Coloproctol. 2023. PMID: 37460830",
    "3. Vanzant E et al. Current fistula management. Curr Opin Crit Care. 2024. PMID: 38441138",
    "4. Parian AM et al. Management of Perianal Crohn's Disease. Am J Gastroenterol. 2023. PMID: 37207318",
    "5. Koch KE et al. Airway Esophageal Fistula. Thorac Surg Clin. 2024. PMID: 39332865",
  ];

  refs.forEach((r, i) => {
    s.addText(r, {
      x: 0.5, y: 4.4 + i * 0.22, w: 9.1, h: 0.22,
      fontSize: 8.5, color: "8AADCC", italic: false
    });
  });
}

// ─── Save ────────────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/fistula-ppt/Fistula_Research_Review.pptx" })
  .then(() => console.log("✅ Saved: /home/daytona/workspace/fistula-ppt/Fistula_Research_Review.pptx"))
  .catch(err => { console.error("❌ Error:", err); process.exit(1); });

cd /home/daytona/workspace/fistula-ppt && node create_ppt.js 2>&1

ls -lh /home/daytona/workspace/fistula-ppt/

Medical diagram showing Parks classification of anal fistula types: intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric fistula tracts in relation to the internal and external anal sphincter muscles, labeled anatomical cross-section illustration

Medical illustration showing tracheoesophageal fistula (TEF) - abnormal connection between trachea and esophagus, with surgical stent placement, clean clinical diagram with labels

Medical diagram of enterocutaneous fistula showing abnormal tract from intestine to skin surface, wound care and fistuloclysis management illustration, clinical educational poster

ls -lh /home/daytona/workspace/fistula-ppt/ && file /home/daytona/workspace/fist…

cd /home/daytona/workspace/fistula-ppt && node create_ppt.js 2>&1 && echo "EXIT:…

ls -lh /home/daytona/workspace/fistula-ppt/Fistula_Research_Review.pptx && pytho…

libreoffice --headless --convert-to pdf /home/daytona/workspace/fistula-ppt/Fist…

cp /home/daytona/workspace/fistula-ppt/Fistula_Research_Review.pptx /tmp/Fistula…

cp /tmp/Fistula_Research_Review.pdf /home/daytona/workspace/fistula-ppt/Fistula_…

Clean medical educational diagram showing Parks classification of anal fistula - four types labeled: intersphincteric, transsphincteric, suprasphincteric, extrasphincteric fistula tracts in cross-section of anal canal with internal and external sphincter muscles clearly labeled, white background, clinical textbook style

Medical infographic showing anal fistula treatment algorithm flowchart: simple fistula leads to fistulotomy, complex fistula leads to LIFT procedure or advancement flap or seton placement, MRI imaging step at top, clean clinical poster style with blue and teal colors

Medical diagram illustrating LIFT procedure (Ligation of Intersphincteric Fistula Tract) step by step - showing the intersphincteric space, identification of fistula tract, ligation and division, surgical anatomy diagram, clean white background, labeled steps

Medical diagram of enterocutaneous fistula showing abnormal tract from small intestine to abdominal skin surface, with labels showing enteral nutrition tube, wound vacuum dressing, fistula output bag - multidisciplinary management illustration, clean educational poster style

Medical illustration showing perianal Crohn's disease fistula with seton placement - showing complex fistula tracts around the anus, seton thread through the tract, surrounding inflamed tissue, with labels for internal opening, external opening, seton, sphincter muscle - clinical educational diagram