"stoma" in /textbooks/9788190568104

"cellulitis" in /textbooks/9788190568104

"diabetic" in /textbooks/9788190568104

"chest drain" in /textbooks/9788190568104

mkdir -p /home/daytona/workspace/surgery-ppt && ls /home/daytona/workspace/surge…

~/surgery-ppt/make_ppt.js

const pptxgen = require("pptxgenjs");
const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Surgical Topics - Das Surgery Reference";

// ─── THEME ────────────────────────────────────────────────
const C = {
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  teal:      "00BFA5",  // teal for stoma section
  orange:    "F4511E",  // orange for cellulitis
  green:     "43A047",  // green for diabetic wound
  purple:    "7B1FA2",  // purple for chest tube
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// ═══════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ═══════════════════════════════════════════════════════════
{
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    { label:"STOMA", x:1.0, color:C.teal },
    { label:"CELLULITIS", x:3.1, color:C.orange },
    { label:"DIABETIC WOUND", x:5.4, color:C.green },
    { label:"CHEST TUBE", x:8.15, color:C.purple },
  ];
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}

// ═══════════════════════════════════════════════════════════
// SLIDE 2 — OVERVIEW / AGENDA
// ═══════════════════════════════════════════════════════════
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    { num:"01", label:"Approach to Stoma", sub:"Types • Pre-op prep • Formation • Complications", color:C.teal },
    { num:"02", label:"Cellulitis", sub:"Definition • Clinical features • Investigations • Management", color:C.orange },
    { num:"03", label:"Diabetic Wound", sub:"Pathophysiology • Classification • Treatment • Amputation", color:C.green },
    { num:"04", label:"Chest Tube (ICD)", sub:"Indications • Technique • Management • Removal", color:C.purple },
  ];

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// ═══════════════════════════════════════════════════════════
// ██ SECTION 1 — STOMA  (color: teal)
// ═══════════════════════════════════════════════════════════
sectionSlide(C.teal, "1", "APPROACH TO STOMA", "Types • Pre-operative Preparation • Formation • Complications");

contentSlide(C.teal, "Definition & Types of Stoma", [
  "Stoma = artificial opening created surgically between a hollow viscus and the skin surface",
  "COLOSTOMY",
  {sub:true, text:"End colostomy – permanent (e.g. abdomino-perineal resection)"},
  {sub:true, text:"Loop colostomy – temporary diversion; defunctioning"},
  {sub:true, text:"Transverse colostomy – for left-sided obstruction"},
  "ILEOSTOMY",
  {sub:true, text:"End ileostomy (Brooke ileostomy) – after total colectomy"},
  {sub:true, text:"Loop ileostomy – protects anastomosis; temporary"},
  {sub:true, text:"Koch pouch (continent) – internal reservoir with valve"},
  "UROSTOMY / ILEAL CONDUIT",
  {sub:true, text:"Urinary diversion after cystectomy"},
  "Site: Right iliac fossa (ileostomy); Left iliac fossa (colostomy)",
], "Das Surgery: Stoma types classified by organ diverted, purpose (permanent/temporary), and construction");

contentSlide(C.teal, "Pre-operative Preparation", [
  "COUNSELLING",
  {sub:true, text:"Thorough explanation by surgeon + stoma nurse"},
  {sub:true, text:"Psychological preparation; discuss body image changes"},
  {sub:true, text:"Patient education on appliance use, skin care"},
  "SITE SELECTION",
  {sub:true, text:"Mark site pre-op – within rectus muscle to prevent hernia"},
  {sub:true, text:"Visible to patient; avoid bony prominences, skin folds, scars"},
  {sub:true, text:"Optimal position – sitting, standing, lying all assessed"},
  "BOWEL PREPARATION",
  {sub:true, text:"Mechanical prep if planned elective procedure"},
  {sub:true, text:"IV antibiotics at induction"},
  "NUTRITIONAL STATUS",
  {sub:true, text:"Correct anaemia, hypoalbuminaemia pre-operatively"},
  {sub:true, text:"High-protein diet; parenteral nutrition if severely malnourished"},
], "Site marking by trained stoma therapist significantly reduces complications");

twoColSlide(C.teal, "Formation of Stoma – Operative Technique",
  "COLOSTOMY FORMATION",
  [
    "Mobilize appropriate colon segment",
    "Divide mesentery preserving blood supply",
    "Bring through abdominal wall via separate trephine wound",
    "Excise circular disc of skin and fat",
    "Cruciate incision through anterior rectus sheath",
    "Split rectus muscle; open posterior sheath",
    "Lumen should pass without tension",
    "Suture bowel to skin using absorbable sutures",
    "Flush end – sutured at skin level",
  ],
  "ILEOSTOMY FORMATION",
  [
    "Spout ileostomy – bowel everted 2–3 cm above skin",
    "Brooke technique: mucosa sutured to dermis",
    "Spout prevents ileal effluent irritating peristomal skin",
    "Check viability – pink, well-perfused mucosa",
    "Appliance fitted in theatre immediately post-op",
    "Loop ileostomy: bridge/rod used to prevent retraction",
    "Closure of loop ileostomy: 6–12 weeks after formation",
  ]
);

contentSlide(C.teal, "Complications of Stoma", [
  "EARLY COMPLICATIONS",
  {sub:true, text:"Ischaemia / Necrosis – inadequate blood supply; re-operation may be needed"},
  {sub:true, text:"Retraction – inadequate mobilization; requires refashioning"},
  {sub:true, text:"Bleeding – usually minor; packing/silver nitrate application"},
  {sub:true, text:"High output (ileostomy) – >1500 mL/day; risk of dehydration, electrolyte imbalance"},
  "LATE COMPLICATIONS",
  {sub:true, text:"Prolapse – bowel telescopes outward; loop > end stoma"},
  {sub:true, text:"Parastomal hernia – most common late complication; mesh repair"},
  {sub:true, text:"Stenosis – narrowing of stoma; dilation or refashioning"},
  {sub:true, text:"Fistulation – communication with adjacent viscus"},
  {sub:true, text:"Skin excoriation – commonest problem; barrier creams, proper appliance"},
  "PSYCHOLOGICAL",
  {sub:true, text:"Body image disturbance; sexual dysfunction; depression"},
  {sub:true, text:"Stoma nurse input essential for rehabilitation"},
], "Bailey & Love: Parastomal hernia occurs in up to 50% within 5 years");

// ═══════════════════════════════════════════════════════════
// ██ SECTION 2 — CELLULITIS  (color: orange)
// ═══════════════════════════════════════════════════════════
sectionSlide(C.orange, "2", "CELLULITIS", "Acute bacterial infection of dermis and subcutaneous tissue");

contentSlide(C.orange, "Cellulitis – Definition, Aetiology & Classification", [
  "DEFINITION: Acute, non-purulent spreading infection of dermis and subcutaneous tissue",
  "CAUSATIVE ORGANISMS",
  {sub:true, text:"Most common: Group A β-haemolytic Streptococcus (Strep. pyogenes)"},
  {sub:true, text:"Also: Staphylococcus aureus (including MRSA in hospital settings)"},
  {sub:true, text:"Immunocompromised: Gram-negative organisms, fungi"},
  {sub:true, text:"Diabetics: polymicrobial – anaerobes + Gram-negatives"},
  "PREDISPOSING FACTORS",
  {sub:true, text:"Breaks in skin: cuts, abrasions, insect bites, ulcers"},
  {sub:true, text:"Lymphoedema, chronic venous insufficiency"},
  {sub:true, text:"Diabetes mellitus, immunosuppression, obesity"},
  {sub:true, text:"Previous cellulitis (recurrence rate ~30%)"},
  "CLASSIFICATION: Non-purulent vs. Purulent (abscess-associated)",
], "Das Surgery: Cellulitis must be distinguished from erysipelas (more superficial, sharply demarcated, lymphangitis prominent)");

twoColSlide(C.orange, "Clinical Features & Investigations of Cellulitis",
  "CLINICAL FEATURES",
  [
    "Local: redness (erythema), warmth, oedema, tenderness",
    "Spreading edge – may mark with pen to monitor",
    "Blistering in severe cases",
    "Lymphangitis – red streak tracking proximally",
    "Lymphadenopathy – regional nodes enlarged, tender",
    "Systemic: fever, rigors, tachycardia, malaise",
    "Severe: bacteraemia, septic shock",
    "Differentiates from DVT, contact dermatitis, gout",
  ],
  "INVESTIGATIONS",
  [
    "Bloods: FBC – raised WBC (neutrophilia)",
    "CRP / ESR – elevated",
    "Blood cultures – if systemic sepsis",
    "Wound swab – from entry point if identifiable",
    "Blood glucose – exclude diabetes",
    "LFT/U&E – baseline, especially if IV antibiotics",
    "Ultrasound – rule out underlying abscess",
    "MRI – if necrotising fasciitis suspected (urgent)",
    "Mark borders with pen; reassess in 24–48 h",
  ]
);

contentSlide(C.orange, "Cellulitis – Treatment & Management", [
  "MILD (Grade 1) – Outpatient oral antibiotics",
  {sub:true, text:"Amoxicillin/clavulanate OR cefalexin for 5–7 days"},
  {sub:true, text:"Penicillin V if Streptococcal cellulitis (no abscess)"},
  {sub:true, text:"Elevation of limb; rest; analgesia"},
  "MODERATE (Grade 2) – Consider IV antibiotics",
  {sub:true, text:"IV Benzylpenicillin + Flucloxacillin (first line UK)"},
  {sub:true, text:"Co-amoxiclav as single agent"},
  {sub:true, text:"Clindamycin if penicillin allergy"},
  "SEVERE / NECROTISING (Grade 3–4)",
  {sub:true, text:"Broad-spectrum IV: Piperacillin-tazobactam ± Metronidazole"},
  {sub:true, text:"Add Vancomycin/Teicoplanin if MRSA suspected"},
  {sub:true, text:"Urgent surgical debridement if necrotising fasciitis (do not delay)"},
  "ADJUNCTS",
  {sub:true, text:"Treat underlying cause (tinea pedis, ulcer, wound)"},
  {sub:true, text:"Anti-fungal for interdigital tinea (recurrence prevention)"},
  {sub:true, text:"Prophylactic penicillin V for recurrent cellulitis (>3 episodes/year)"},
], "Necrotising fasciitis = surgical emergency – finger test, 'dishwater pus', wood-hard oedema");

// ═══════════════════════════════════════════════════════════
// ██ SECTION 3 — DIABETIC WOUND  (color: green)
// ═══════════════════════════════════════════════════════════
sectionSlide(C.green, "3", "DIABETIC WOUND", "Pathophysiology • Wagner Classification • Management Principles");

contentSlide(C.green, "Diabetic Wound – Pathophysiology", [
  "Diabetes impairs wound healing through multiple mechanisms:",
  "NEUROPATHY",
  {sub:true, text:"Peripheral sensory neuropathy → painless trauma → unrecognised injury"},
  {sub:true, text:"Autonomic neuropathy → dry skin, fissures, reduced sweating"},
  {sub:true, text:"Motor neuropathy → intrinsic muscle wasting → foot deformities (claw toes, high arch)"},
  "VASCULOPATHY",
  {sub:true, text:"Macrovascular – PVD; reduced blood flow to foot"},
  {sub:true, text:"Microvascular – capillary basement membrane thickening; poor tissue oxygenation"},
  "IMMUNE DYSFUNCTION",
  {sub:true, text:"Impaired neutrophil chemotaxis and phagocytosis"},
  {sub:true, text:"Reduced T-cell function → increased susceptibility to infection"},
  "ALTERED WOUND BIOLOGY",
  {sub:true, text:"Reduced growth factor production (VEGF, PDGF, EGF)"},
  {sub:true, text:"Glycated collagen – impaired cross-linking; poor tensile strength"},
  {sub:true, text:"Advanced glycation end-products (AGEs) → chronic inflammation"},
], "Das Surgery: Triple pathology – neuropathy + ischaemia + infection = limb-threatening");

contentSlide(C.green, "Wagner Classification of Diabetic Foot Ulcer", [
  "GRADE 0 – Intact skin; bony deformity / pre-ulcerative lesion; callus",
  "GRADE 1 – Superficial ulcer; epidermis ± dermis; no subcutaneous involvement",
  "GRADE 2 – Deep ulcer to tendon, capsule or bone; no abscess or osteomyelitis",
  "GRADE 3 – Deep ulcer with abscess, osteomyelitis or joint sepsis",
  "GRADE 4 – Gangrene of forefoot / toes",
  "GRADE 5 – Gangrene of whole foot",
  "CLINICAL ASSESSMENT OF DIABETIC FOOT",
  {sub:true, text:"Neuropathic ulcer: plantar surface, painless, punched-out, warm foot, good pulses"},
  {sub:true, text:"Ischaemic ulcer: margins, painful, dry gangrene, absent pulses, cold foot"},
  {sub:true, text:"Neuroischaemic: combination – most common in clinical practice"},
  {sub:true, text:"'Probe to bone' test – positive = high PPV for osteomyelitis"},
], "Bailey & Love Fig 43.11: Severe diabetic foot with necrosis – neuropathic with hindfoot deformity");

twoColSlide(C.green, "Diabetic Wound – Investigations & Management",
  "INVESTIGATIONS",
  [
    "Bloods: FBC, CRP, ESR, HbA1c, RFT, LFT",
    "Wound swab (surface) – limited value",
    "Deep tissue biopsy / bone biopsy for culture",
    "Plain X-ray: gas in tissue, bony destruction (osteomyelitis)",
    "MRI foot: most sensitive for osteomyelitis (gold standard)",
    "ABPI / Doppler for vascular status",
    "Angiography if revascularization planned",
    "Echocardiography if cardiac assessment needed pre-op",
  ],
  "MANAGEMENT PRINCIPLES",
  [
    "Glycaemic control – critical; target HbA1c <53 mmol/mol",
    "Wound debridement – sharp debridement of slough and callus",
    "Offloading – total contact cast / therapeutic footwear",
    "Antibiotics: tailored to culture; empirical cover",
    "  - Mild: oral Amoxicillin/clavulanate or Cefalexin",
    "  - Severe: IV Piperacillin-tazobactam + Metronidazole",
    "  - MRSA: add Vancomycin/Daptomycin",
    "Vascular intervention: angioplasty / bypass if ischaemic",
    "Maggot therapy / VAC (negative pressure wound therapy)",
    "Amputation if uncontrolled infection / gangrene",
  ]
);

contentSlide(C.green, "Diabetic Wound – Surgical Options & Amputation", [
  "SURGICAL DEBRIDEMENT",
  {sub:true, text:"Indicated for collections, necrotic tissue, extensive osteomyelitis"},
  {sub:true, text:"Remove all infected bone; allow tension-free skin closure"},
  {sub:true, text:"Distinguish superficial osteitis (skin loss only) from true osteomyelitis"},
  "REVASCULARISATION",
  {sub:true, text:"Mandatory vascular assessment if absent/reduced peripheral pulses"},
  {sub:true, text:"Percutaneous angioplasty or distal bypass – improves limb salvage"},
  "AMPUTATION",
  {sub:true, text:"Not an easy option – wound healing unreliable in diabetics"},
  {sub:true, text:"Digital / ray amputation – single toe/metatarsal"},
  {sub:true, text:"Transmetatarsal amputation – preserve forefoot function"},
  {sub:true, text:"Below-knee (BK) amputation – preferred over AK; better rehabilitation"},
  {sub:true, text:"Cut through area with better sensation and vascularity"},
  {sub:true, text:"Guillotine amputation if sepsis control needed urgently, then formal stump closure"},
  "MDT APPROACH",
  {sub:true, text:"Surgeon + Diabetologist + Vascular surgeon + Orthotist + Wound-care nurse"},
], "Bailey & Love: One-fifth of diabetic foot ulcers result in amputation – early aggressive management is key");

// ═══════════════════════════════════════════════════════════
// ██ SECTION 4 — CHEST TUBE / ICD  (color: purple)
// ═══════════════════════════════════════════════════════════
sectionSlide(C.purple, "4", "CHEST TUBE (ICD)", "Intercostal Drain – Indications • Technique • Management • Removal");

contentSlide(C.purple, "Intercostal Drain – Indications & Contraindications", [
  "INDICATIONS",
  {sub:true, text:"Pneumothorax: tension (emergency), large simple, failed needle aspiration"},
  {sub:true, text:"Haemothorax: traumatic or spontaneous bleeding into pleural space"},
  {sub:true, text:"Haemopneumothorax: blood + air (common in trauma)"},
  {sub:true, text:"Pleural effusion: large symptomatic / malignant / empyema"},
  {sub:true, text:"Empyema thoracis: frank pus in pleural space"},
  {sub:true, text:"Chylothorax: lymphatic fluid accumulation"},
  {sub:true, text:"Post-thoracotomy / cardiac surgery: routine drainage"},
  {sub:true, text:"Prophylaxis: during positive pressure ventilation with pneumothorax"},
  "CONTRAINDICATIONS (Relative)",
  {sub:true, text:"Coagulopathy (correct INR <1.5 if possible)"},
  {sub:true, text:"Skin infection at insertion site"},
  {sub:true, text:"Adhesions / loculated effusion – ultrasound guidance essential"},
  {sub:true, text:"Single lung (contralateral pneumonectomy) – extreme caution"},
], "Das Surgery (p.403–404): Tension pneumothorax – trachea deviates away; immediate aspiration 2nd ICS lifesaving");

contentSlide(C.purple, "Chest Tube – Equipment & Technique", [
  "EQUIPMENT",
  {sub:true, text:"Drain sizes: Small (14–20 Fr) – pneumothorax, effusion | Large (28–36 Fr) – haemothorax, empyema"},
  {sub:true, text:"Underwater seal drainage (UWS) bottle – filled with 500 mL sterile water"},
  {sub:true, text:"Scalpel, artery forceps, suture (0-silk / 0-prolene), sterile drapes"},
  "SAFE TRIANGLE FOR INSERTION",
  {sub:true, text:"Anterior border of latissimus dorsi"},
  {sub:true, text:"Lateral border of pectoralis major"},
  {sub:true, text:"Apex: axilla; base: horizontal line at nipple level"},
  {sub:true, text:"5th intercostal space, mid-axillary line (most common site)"},
  "TECHNIQUE (Blunt Dissection – BTS guidelines):",
  {sub:true, text:"1. Position: supine or 45°; arm abducted"},
  {sub:true, text:"2. Skin prep + drape; infiltrate LA (skin, periosteum, parietal pleura)"},
  {sub:true, text:"3. 2–3 cm incision over UPPER border of lower rib (avoid neurovascular bundle)"},
  {sub:true, text:"4. Blunt dissect through intercostal muscles with artery forceps"},
  {sub:true, text:"5. Finger sweep to clear adhesions and confirm pleural entry"},
  {sub:true, text:"6. Introduce drain (clamp tip); direct posteriorly/superiorly"},
  {sub:true, text:"7. Connect to UWS; confirm swing/bubbling; secure with purse-string or mattress suture"},
], "CRITICAL: Stay above the rib to avoid intercostal vein, artery and nerve");

twoColSlide(C.purple, "Chest Tube – Management & Troubleshooting",
  "MANAGEMENT (Ongoing)",
  [
    "UWS bottle – keep 50 cm below chest level at all times",
    "Monitor: swing (respiratory oscillation confirms patent drain)",
    "Bubbling on expiration = air leak from lung",
    "Record drainage volume hourly (trauma) or 4-hourly",
    "Do NOT clamp routinely (risk of tension pneumothorax)",
    "Clamp only: to change bottle, during transfer, or on removal",
    "CXR immediately post-insertion; daily thereafter",
    "Physiotherapy – deep breathing, mobilisation",
    "Flush drain with 20 mL saline if blocking (fibrinous exudate)",
    "Streptokinase instillation for loculated empyema (BTS protocol)",
  ],
  "COMPLICATIONS",
  [
    "Malposition – kinking, subcutaneous, intra-fissural",
    "Haemorrhage – intercostal vessel injury",
    "Lung laceration / pneumothorax from trocar",
    "Infection – empyema (strict aseptic technique)",
    "Subcutaneous emphysema – fenestration outside chest wall",
    "Blocked drain – milk / flush; re-insert if needed",
    "Re-expansion pulmonary oedema – drain >1.5L at once",
    "Diaphragm / liver / spleen injury (avoid low insertion)",
    "Persistent air leak >5 days – consider surgery (VATS)",
  ]
);

contentSlide(C.purple, "Chest Tube – Removal (Procedure)", [
  "CRITERIA FOR REMOVAL",
  {sub:true, text:"No bubbling for 24 hours (no air leak)"},
  {sub:true, text:"Drainage <150 mL/day (some say <100 mL)"},
  {sub:true, text:"Lung fully re-expanded on CXR"},
  {sub:true, text:"Clinically improving"},
  "PROCEDURE FOR REMOVAL (Das Surgery / Pye's Surgical Handicraft)",
  {sub:true, text:"Explain procedure; analgesia pre-removal"},
  {sub:true, text:"Clamp drain; confirm stability on CXR"},
  {sub:true, text:"Position: supine or sitting"},
  {sub:true, text:"Remove securing suture; leave closure suture in place"},
  {sub:true, text:"Ask patient to perform Valsalva manoeuvre (maximum inspiration held) – OR exhale completely"},
  {sub:true, text:"Withdraw drain rapidly in one smooth pull"},
  {sub:true, text:"Simultaneously tie the mattress/purse-string closure suture"},
  {sub:true, text:"Apply petroleum jelly gauze (Vaseline gauze) dressing immediately"},
  {sub:true, text:"CXR at 1 hour and 24 hours post-removal to exclude pneumothorax"},
  "NOTE: Valsalva prevents air entering pleural space on withdrawal",
], "Das Surgery p.403–414: Drain management is part of postoperative chest complication care");

// ═══════════════════════════════════════════════════════════
// FINAL SLIDE – SUMMARY
// ═══════════════════════════════════════════════════════════
{
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  sl.addShape(pres.ShapeType.rect, { x:0, y:0, w:SLIDE_W, h:0.1, fill:{ color:C.accentBlue } });
  sl.addShape(pres.ShapeType.rect, { x:0, y:SLIDE_H-0.1, w:SLIDE_W, h:0.1, fill:{ color:C.accentBlue } });

  sl.addText("KEY TAKE-AWAYS", { x:0.5, y:0.2, w:9, h:0.6, fontSize:22, bold:true, color:C.white, align:"center", charSpacing:5 });

  const summ = [
    { color:C.teal,   label:"STOMA",          text:"Site mark pre-op within rectus muscle • Spout ileostomy prevents skin injury • Monitor for ischaemia, retraction, high output early" },
    { color:C.orange, label:"CELLULITIS",      text:"Mark borders to track spread • IV Benzylpenicillin + Flucloxacillin for moderate disease • Urgent surgery if necrotising fasciitis suspected" },
    { color:C.green,  label:"DIABETIC WOUND",  text:"Triple pathology: neuropathy + ischaemia + infection • Wagner grading guides management • MDT approach; VAC therapy; BK amputation preferred" },
    { color:C.purple, label:"CHEST TUBE",      text:"Safe triangle insertion • Stay above rib • Blunt dissection + finger sweep • Valsalva on removal • Post-removal CXR mandatory" },
  ];

  summ.forEach((s, i) => {
    const yy = 0.95 + i * 1.1;
    sl.addShape(pres.ShapeType.rect, { x:0.3, y:yy, w:9.4, h:0.95, fill:{ color:"132233" }, line:{ color:s.color, width:1.5 } });
    sl.addShape(pres.ShapeType.rect, { x:0.3, y:yy, w:1.5, h:0.95, fill:{ color:s.color } });
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  sl.addText("Ref: S. Das – A Manual on Clinical Surgery, 13th Ed. | Bailey & Love 28th Ed.", { x:0.3, y:5.25, w:9.4, h:0.28, fontSize:9.5, italic:true, color:"607D8B", align:"center" });
}

// ─── WRITE FILE ────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/surgery-ppt/Surgical_Topics_Das_Surgery.pptx" })
  .then(() => console.log("✅ PPT saved successfully!"))
  .catch(err => console.error("❌ Error:", err));

cd /home/daytona/workspace/surgery-ppt && node make_ppt.js

ls -lh /home/daytona/workspace/surgery-ppt/Surgical_Topics_Das_Surgery.pptx

libreoffice --headless --convert-to pdf "/home/daytona/workspace/surgery-ppt/Sur…

cp "/home/daytona/workspace/surgery-ppt/Surgical_Topics_Das_Surgery.pptx" /tmp/s…