Respectful Insolence

What’s wrong with Steve Jobs?

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Regular readers of this blog know that I’m an Apple geek. The Macintosh is my preferred axe and has been, with few interruptions, since the late 1980s. Indeed, the only time I’ve used anything other than a Mac is when I’ve had no choice. The first time I saw one was in 1984, not long after the original Mac was released. My roommate somehow managed to come up with the money to buy one through the University of Michigan towards the end of my senior year. I really liked it right from the start but only got to play with it occasionally for a few months. After I graduated, I didn’t even own a computer for several years and hardly touched one. I had entered medical school, and this was the mid-1980s. As amazing as it sounds, we didn’t even have e-mail accounts, much less computers to use. How on earth did we manage? Who knows? But somehow we did.

In the late 1980s, I finally got a chance to use computers again while doing a research project in my last year of medical school. It was a Mac SE. Since then, I have used the Macintosh platform more or less continuously, with few exceptions or hiatuses. For example, back in the early 1990s, I was forced to use Windows 3.0 and 3.1 for a while, because that’s all that was around in the labs that I worked in. Even so, the first computer I purchased was a Mac LC back in 1990 or 1991, and I haven’t owned anything other than a Mac since then. True, there were some times when I was forced to use Windows simply because I needed an application that was either not available on the Mac or whose Mac version hadn’t been updated in eons. There were a few times when I was tempted to jump ship, particularly during the “bad years” of the mid-1990s, when Apple lost its way, and its offerings became nearly indistinguishable from Windows boxes. Two of the institutions I’ve worked in, particularly the one I work in now, have ranged from Mac-indifferent to downright Mac-hostile, where Macs are barely tolerated only because a few high-ranking faculty insist on using Apple products and IT is utterly clueless about the Mac.

All of this is my typical long-winded way of saying that I care what happens to Apple, and I always take notice when people start speculating about the health of Steve Jobs, one of the two original founders of Apple and the man who was most responsible for Apple’s resurgence over the last decade. Four years ago, he was unfortunate enough to develop pancreatic cancer, but amazingly, astoundingly fortunate enough that he developed an uncommon form of pancreatic cancer that is highly treatable for cure with simple surgical excision. Apparently he pursued a bit of woo first, but ultimately he underwent the surgery. Fortunately for Jobs, his was a slow-growing tumor, and the delay in surgery did not harm him.

Now, shareholders are concerned about how gaunt Jobs has appeared recently, so much so that apparently it’s affecting investor confidence:

Jobs’s health has been a renewed focus as of late, particularly on Wall Street, with fund managers and other large Apple investors expressing concern that the company co-founder’s cancer may have recently returned.

Much of that fear stemmed from Jobs’ gaunt appearance during Apple’s developers conference last month and at other recent engagements related to the launch of his firm’s new iPhone 3G handset.

Others are calling for a more well-defined succession plan or even for Jobs to step down, and it’s been pointed out that Apple is so identified with Jobs that if Jobs ever had to step down Apple would be likely to lose $20 billion in market value instantly. I have to admit, recent photos show him looking pretty gaunt. However, fears that Jobs’ tumor has come back are almost certainly overblown. The reason is that he had an islet cell neuroendocrine tumor of the pancreas, for which complete surgical excision is almost always curative. Recurrence is uncommon. No, it would be pretty remarkable if that’s what was going on.

So why does Steve Jobs look so unhealthy these days?

One explanation that was given was that, around the time of the launch of the second-generation iPhone in June was this:

Responding to questions on the matter Tuesday, a spokesperson for the Cupertino-based electronics maker told the financial paper that Jobs has been plagued by a “common bug” in recent weeks, but that he felt it essential that he make good on delivering the opening keynote address at the annual Apple developer conference and personally take the wraps off the company’s new 3G iPhone.

If that was true, however, it doesn’t explain how much thinner Jobs looks than he used to be or why he’s looked bad enough for long enough that speculation about his health keeps rearing its ugly head. From my reading of what can be gleaned from the news, to me it seems likely is that he is suffering from nutritional complications of his original surgery, which seems even more likely given that it was recently revealed that Jobs underwent a second operation related to his original surgery:

Steve Jobs is reassuring some of his closest associates that rumors of his health are greatly exaggerated, but is telling those same people that he underwent a procedure this year related to his weight loss, the New York Times is reporting.

“[In] recent weeks, Mr. Jobs has reassured several people that he is doing well and that four years after a successful operation to treat a rare form of pancreatic cancer, he is cancer free,” the paper said.

However, the Apple chief executive has reportedly admitted to some of those people that he had a surgical procedure earlier this year to address an issue that was causing him to lose weight.

I think I know what’s going on here, at least as well as can be known with the little information that’s been given. I admit that my thoughts are speculation, but I hope they’re more of an educated guess than just pulling something out of my nether regions.

Jobs underwent an operation known as the Whipple operation, otherwise known as a pancreaticoduodenectomy. This is a huge operation, one of the biggest and most radical rearrangements of a patient’s anatomy that is done routinely. What’s done is that the head of the pancreas and duodenum are removed en bloc (mainly because their close proximity to each other and their shared blood supply make it virtually impossible to remove the pancreatic head alone. This tour de force operation then necessitates putting things back together thusly:

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There are many potential complications of the Whipple procedure, because it’s a big operation and it’s an operation on the pancreas. There’s a famous saying in surgery that goes, “Eat when you can, sleep when you can, but don’t mess with the pancreas.” (Usually another, far less savory word than “mess” is used.) In any case, there are almost always long term nutritional consequences that derive from rearranging a patient’s anatomy in so radical a fashion. First off, patients almost always lose 5-15% of their body weight right off the bat, although that usually levels off fairly quickly. Jobs, however, was never exactly what you would call robust-looking. He was always thin; so losing that much weight for him could be more problematic. Although it has been speculated that Steve Jobs is a vegan or vegetarian, apparently such is not the case (he’s a so-called pescetarian, meaning he will eat seafood in addition to vegetables, fruit, grains, and dairy); so post-surgical difficulties maintaining nutrition because of a special diet that doesn’t mesh well with Jobs’ new anatomy are probably not what’s going on here. Some other potential serious problems over the long term include glucose intolerance or even diabetes requiring insulin; malabsorption because of diminished production of pancreatic enzymes; delayed gastric emptying; the afferent loop syndrome; or the “dumping syndrome,” which is common after stomach resections and results from undigested food being “dumped” too fast into the proximal small intestine, which draws in fluid.

Of course, his surgery was nearly four years ago. Usually by this long out, these problems will have resolved or at least stabilized, so why is Jobs apparently looking worse now?

I emphasize again that this is just my guess, but the admission that Jobs had an unnamed procedure or operation gives me enough of a clue to what’s probably going on. Chances are, Jobs had either dumping syndrome or afferent loop syndrome. Of the two, given that he underwent a procedure, the latter strikes me as more likely, because surgery is much less common used to correct dumping. That’s because the troublesome symptoms of dumping can often be managed pretty well medically with octreotide and other drugs. The treatment of afferent limb syndrome (ALS), however, is almost always surgical. It is a mechanical problem and requires a mechanical solution.

You’ve probably never heard of it unless you’ve been unfortunate enough to have it (or are a surgeon or gastroenterologist), but ALS is a potential complication after a certain type of gastrojejunostomy, which is when the stomach is connected to a loop of small bowel in an anastomosis. This leaves two “loops.” The efferent loop is the small bowel leading away from the anastomosis. The afferent loop is the loop proximal to the anastomosis, whose peristalsis runs towards the anastomosis. Bile and pancreatic juice dump into the afferent loop, as can be seen in the illustration above. If there is a mechanical problem with the afferent loop, it can result in symptoms soon after surgery or as long as many years later. That Jobs seems to be rather quickly looking worse nearly four years after his operation also suggests ALS.

There are two forms of the problem, acute and chronic. Acute ALS involves a high grade obstruction of the afferent limb, in which pancreatic juices and bile back up behind the obstruction under pressure, and is potentially life-threatening. The more common and chronic form is what can produce nutritional deficiencies over time. Usually, approximately 10-20 minutes to an hour after a meal, the patient will experience abdominal fullness and pain as the liver and pancreas pump bile and pancreatic juice into the partially obstructed afferent limb. These symptoms usually last from several minutes to an hour, although they occasionally last as long as several days. Pressure will build up and the obstruction will resolve by then, sometimes with vomiting. Prolonged ALS with stasis of digestive juices in the afferent limb can result in bacterial overgrowth of the digestive juices sitting there, fatty stools, diarrhea, and vitamin B-12 deficiency.

The treatment, as I mentioned before, is surgical. Basically, the connection between the stomach and the duodenum must be revised. Usually, one of two operations are necessary. Either the gastrojejunostomy has to be converted to what’s known as a Billroth I gastroduodenostomy, in which the end of the stomach is directly connected to the end of the duodenum. This is usually not an option after a Whipple operation for simple anatomic reasons. In Jobs’ case, I speculate, that leaves the second option of a Roux-en-Y gastrojejunostomy.

I could be entirely wrong, of course but from what we know, my speculation makes medical and surgical sense. If the cause of Jobs’ nutritional problems was indeed afferent loop syndrome, then the treatment would be to operate and fix whatever the problem with the afferent loop is. I will point out that an alternate explanation for Jobs undergoing a procedure related to his nutrition is that he could have undergone the placement of a feeding jejunostomy tube, so that nutritional supplementation could be administered directly into his small intestine downstream from its anastomosis with the stomach. The only way I could picture a surgeon recommending that option, though, is if Jobs happens to be one of the small number of patients who have serious nutritional difficulties after a Whipple operation whose cause cannot be determined. This does happen. In such cases, what’s important is to fix his nutritional status and keep trying to figure out the cause if possible. Finally, it could still be the dumping syndrome; sometimes dumping is so bad that surgery, either to do a Roux-en-Y or a Billroth I conversion becomes necessary. Another treatment option for dumping that is sometimes done is to reverse a length of small bowel, so that its peristalsis runs reverse to the normal direction, as a means of slowing down the rapid entry of undigested food into the small intestine.

What’s more important, though, is that Jobs’ appearance (at least as far as I can tell from the limited information that I have) is almost certainly not due to a recurrence of his tumor, and it’s not something that can’t be fixed. Chances are Jobs will be fine, and will remain as cantankerous, arrogant, dictatorial, and wildly visionary as ever for many years to come. Whether he’ll choose to remain at Apple for many years to come, of course, no one but Jobs can say, but it’s unlikely to be his current health problems that motivate him to leave, when leave he inevitably does.

Now I have to go and upgrade my iPhone to the new 3G version, while wishing Jobs well. On second thought, I suppose that I can wait. 16 GB isn’t enough to entice me, even with the faster 3G Internet and the built-in GPS. The new software for the iPhone does most of what I wanted already, namely allowing me to access the Exchange server that my cancer center uses and to download stupid applications, like the one that produces a light saber with light saber noise as I move the phone about. Besides, I really could use more room to store my tunes and movies.

Comments

  1. #1 SLC
    July 24, 2008

    Actually, with the new Intel based MACs, using a program like Parallels, one can run any number of operating systems (e.g. Windows, various LINUX systems, etc.) simultaneously, provided one has sufficient memory

  2. #2 John S. Wilkins
    July 24, 2008

    I’ve tried Parallels and VMWare and much prefer the latter. It’s easier and doesn’t involve partitions and such. And it runs PhotoShop faster enough that I can’t tell it’s not running natively.

    Thanks for the confidence building about Apple. I may buy some stock if it drops low enough…

  3. #3 Confuseddave
    July 24, 2008

    Just to prevent any proper confusion, Afferent Loop Syndrome is a different ALS to Amyotrophic Lateral Sclerosis (a form of motor neuron disease characterised by increasing muscle weakness).

  4. #4 DLC
    July 24, 2008

    Some eons ago, I worked for a place where the chief of the IT department was a mac fan. In an office of about 40 units we had maybe 6 macs. When windows 95 came out, we installed it in a couple IT dept machines first, as a testbed. When I got the install up and running, my boss and I both said : “Wait… that’s Mac OS . . .” I hope Steve Jobs is well and can hand the company off to a quality successor when he feels like it, and not when his health demands he do so.

  5. #5 PaulT
    July 24, 2008

    I was just reading about a so-called “product transition” coming in the next couple of months. Whatever this is, they’re warning it’ll the company profits in the short term, and this may also be affecting the share price.

    Cue speculation about what the transition is. Switching from Intel to AMD processors? Multi-touch tablet Mac? Introducing monitor-less mid range Macs, somewhere between Mac Mini and Mac Pro? Apple TV acquiring gaming capabilities? Apple buying Adobe? Who knows?

  6. #6 Brian
    July 24, 2008

    I respect that you’re able to present your opinion about Apple products as just that – opinion. Some folks tend to get just a little too smug for my taste.

  7. #7 BB
    July 24, 2008

    According to MacWorld, Jobs is into macrobiotics, veganism, and so forth. That unhealthy look may be part of his dietary habits.

  8. #8 Mike O'Risal
    July 24, 2008

    Only marginally related (cancer woo), but I’ve attempted a takedown of some cell phone EM woo that’s been run as frontpage news in my hometown paper. You could probably do a much better job than I did, particularly because you’re probably more familiar with the oncologist at its source than I am. Please check it out.

    I look forward to the shredding that’s sure to come.

  9. #9 Warren
    July 24, 2008

    PaulT:

    Cue speculation about what the transition is.

    An upgraded AppleTV that functions as a DVR? (IOW, an AppleTV that I would actually want to buy.)

  10. #10 BB
    July 24, 2008

    I second Mike O’Risal’s call to blog about Ron Herberman and cell phones. He’s a major personage, not one I’d think of as a woo-meister by any means. It was a big story on the evening news in NYC yesterday.

  11. #11 Jon H
    July 24, 2008

    “Whatever this is, they’re warning it’ll the company profits in the short term, and this may also be affecting the share price”

    They’re always pretty conservative and modest with their guidance. So Wall Street freaks out every quarter even when Apple announces record profits.

    My guess would be iPod price cuts, possibly MacBook price cuts.

  12. #12 Jon H
    July 24, 2008

    It would be nice if Apple’s Remote software for controlling an AppleTV from an iPhone or iPod touch were expanded to providing a general wireless multi-touch interface for Apple TV. It could be used as a wireless game control, or for manipulating photos on the TV.

  13. #13 DavidCT
    July 24, 2008

    I started with computers with an Osborne 1 running CPM (an operating system used in the late Cretaceous period). Because I knew Wordstar and had no crying need for Visicalc I migrated into PCs. After years of bloatware and blue screens, I now have an Intel MacBook. It is nice to have a machine that boots up within the same day that I want to use it. Glad to hear that Steve Jobs will likely be with us a bit longer. I hate it when my technology is discontinued ( CPM, Royal Enfield, Sony Beta). Yes I am almost as old as god.

  14. #14 Green Eagle
    July 24, 2008

    Remember the last time that the Apple people decided they didn’t need Steve Jobs? The company began an immediate aimless drift downward. They finally brought him back, and things have been pretty good for them.

    Whatever else you think of him, Jobs is one of the greatest salesmen in the history of mankind. He has constantly managed to surround his products with a gloss of superiority, whatever the truth. Apple will have a tough time indeed after he is gone.

  15. #15 Sailor
    July 24, 2008

    Re: cell phones:
    On the one hand there is no evidence yet that cell phones can give you cancer. On the other hand in the last few years we have millions of young kids using them, and we have no idea if this will have an effect in 50 or 60 years.
    Wise parents might try to limit how much time they use them.
    We do not always know. when I was a kid we spent long periods in the shoe shops watching our toes wiggling in flouroscopes. Nowdays when you get an Xray, everyone else leaves the room. I am not sure we were harmed, but no one would allow it now. Caution is not a bad thing, especially when dealing with the young.

  16. #16 isles
    July 25, 2008

    According to MacWorld, Jobs is into macrobiotics, veganism, and so forth. That unhealthy look may be part of his dietary habits.

    I was thinking that too. It’s remarkable that, so often, a person who is a genius in one area is befuddled by another.

  17. #17 LC
    July 25, 2008

    Not being a medico, I’m trying to see exactly what the Whipple procedure does in simpler terms – at least with electronics you can just swap out the broken parts one for one.

    A normal system seems to be: stomach, duodenum with ducts for pancreas and bile, small intestine.

    A post-Whipple setup (from reading and pictures) seems to be: ducts for bile and pancreas, bit of small intestine, stomach attachment, small intestine (with some parts removed – duodenum, gall bladder, etc).

    Why the differing order of attachment? I would assume that you want to soak the food in the bile and pancreatic enzymes _before_ it gets to the small intestine, and the lack of the ‘gateway function’ of the duodenum means the system would be prone to clogging up unless they lived on a liquid/semi liquid diet.

    I assume the pancreas can’t regenerate like the liver, so cutting off the problem parts isn’t an option? Or if the common blood supply of the duedenum/pancreas is a problem, why not bypass it and work on one part as opposed to total rebuilding.

  18. #18 SLC
    July 25, 2008

    Re John Wilkins

    Most reviews of Parallels and VMWare seem to take the position that it’s six of one and a half dozen of the other. The difficulty of making a choice is that, apparently, the two companies are competing fiercely so that updates and upgrades appear all too often. Thus, todays’ review is usually obsolete by the time forking over the gelt arrives.

  19. #19 Samia
    July 25, 2008

    Orac, great post. I’m not much of an Apple fangirl, but the 3G looks quite tasty. I’m hoping to get a Touch someday when they aren’t ridiculously expensive. I hope Jobs’ cancer is not a factor in his pallid demeanor. Re: some of the comments, I’m not exactly getting what’s wrong with veganism? I know that there are plenty of wrong ways to go about any type of diet, but just throwing the word out there like it’s synonymous with woo is a little weird to me.

  20. #20 iAn
    July 25, 2008

    Steve Jobs is growing old. That affects one’s appearance. Apple has started referring to this condition as i’Maged.

    You can confirm this using iSpy software. Run your iMage of Jobs (above) thru that, and it clearly reveals that he’s injecting his thumb (by means of a iPodermic) with an anti-aging medication, possibly some sort of extract from an iGuana, or an iDleweiss plant.

    These medications have been shown to offer some iMmunity to aging.

    Hope this helps.

  21. #21 Lancelot Gobbo
    July 25, 2008

    Since they mention ‘a bug’ how about a blind loop syndrome with bacterial overgrowth and malabsorption?

  22. #22 DeadGuyKai
    July 25, 2008

    One has to wonder if Jobs will live long enough to go to jail for backdating his stock options.

    He’s the asshole all the Apple iGeeks think Bill Gates is.

    ———

    Yo Orac! Miss you in alt.revisionism!

  23. #23 retiarius
    July 26, 2008

    > “live long enough to go to jail for backdating”

    You must have missed the lecture-hall class whereby it was revealed
    that not only the SEC, but the DOJ, bypassed any prosecution in either
    the civil or criminal realms. Jobs has testified via deposition
    in the Heinen civil case. Are you banking on a perjury trap?

    Otherwise, ‘sjobs’ has lived long enough to do succession planning,
    mapping out the technical underpinnings of the next iPhone (or two,
    per public quotation on CNBC talking-head shows), and several other
    things that should make a mere mortal such as yourself jealous.

  24. #24 Jon H
    July 26, 2008

    BB wrote: “According to MacWorld, Jobs is into macrobiotics, veganism, and so forth. That unhealthy look may be part of his dietary habits.”

    He’s been into that for decades, but only recently looked so gaunt. Unless his diet is incompatible with his newly-configured digestive system, it’s probably not a matter of diet.

  25. #25 DeadGuyKai
    July 26, 2008

    retiarius spewed: You must have missed the lecture-hall class whereby it was revealed that not only the SEC, but the DOJ, bypassed any prosecution in either the civil or criminal realms.

    Wow, a rich white guy got a free pass from the Bush DOJ. Who would’a thunk it?

    We’ll see if that continues to be the case in the future. I don’t think the SoL has passed for Mr. Jobs’ activities yet.

  26. #26 KenC
    July 26, 2008

    My brother and I spoke about Steve’s latest surgery, the other day, while on vacation. He’s a pediatric heart surgeon. Anyway, he thinks Steve had the reverse jejunem procedure that you mention as an alternative treatment for his dumping problems.

  27. #27 LucidSplash
    July 26, 2008

    LC,

    If I’m not mistaken, the duodenum is actually part of the small intestine in the normal setup and is where the pancreatic juices and bile are added to the results of initial digestion in the stomach. So the Whipple actually tries to stay true to the original order by keeping the pancreatic and bile ducts emptying into the remainder of the small intestine. Additionally, the pancreatic enzymes and bile need a less acidic environment for activity than provided by the stomach so mixing them in the stomach wouldn’t have the desired effect. In the normal anatomy, the results of digestion in the stomach are immediately neutralized on entry into the duodenum by bicarbonate from the pancreas which protects the small intestine from acidity it can’t really handle for prolonged periods and also activates the pancreatic enzymes.

    I hope that helped!

  28. #28 LC
    July 27, 2008

    @Lucid

    Yes it did help and provided a bit more intersting information (I was never quite sure how the stomach acid/food mix was neutralised) – thank you :)

    I’ll stick with machines though as sometimes a good thump can fix a machine, but giving an organic a good thump results in a lawsuit.

  29. #29 Agatha Sadler
    July 27, 2008

    Wow, this guy needs to get a life.

  30. #30 Marcus Ranum
    July 28, 2008

    Remember Digital, CDC, Convex, Sequent, Apollo, Commodore – whatever? These things we’re all playing with are just toys for a handful and tools for the rest of us. Nobody’ll remember them in a few decades because they’ll only be interesting as parts of the fossil transitional forms of late 20th century computing. You cannot afford to get attached to this stuff any more than you should have gotten attached to paper punch tape (I actually liked that stuff!) or 5 1/2″ floppy disks.

    WRT to Jobs – he eats a woo diet, doesn’t he? To me, he just looks like a typical vegan skinny wimp. Get that man some heavy fuel and he’ll be fine.

  31. #31 Fernando Leiria
    July 28, 2008

    THANKS for your explantion, Orac

  32. #32 LocutusIX
    July 28, 2008

    The vegan diet is not an unhealthy diet. There are millions of vegans thriving on it. In fact, when properly done, has shown to be far healthier than the diet of meat-eaters. If Jobs is vegan, it would increase his longevity (on average), decrease his risk of heart problems, and overall would have tendency to improve his quality of life.

    I wouldn’t blame his health problems on his diet, especially if it is as healthy as reported.

  33. #33 Fernando Leiria
    July 28, 2008

    THANKS for your explantion, Orac

  34. #34 Fernando Leiria
    July 28, 2008

    THANKS for your explantion, Orac

  35. #35 Fernando Leiria
    July 28, 2008

    THANKS for your explantion, Orac

  36. #36 Fernando Leiria
    July 28, 2008

    THANKS for your explantion, Orac

  37. #37 Fernando Leiria
    July 28, 2008

    THANKS for your explantion, Orac

  38. #38 Fernando Leiria
    July 28, 2008

    THANKS for your explantion, Orac

  39. #39 Fernando Leiria
    July 28, 2008

    THANKS for your explantion, Orac

  40. #40 Fernando Leiria
    July 28, 2008

    THANKS for your explantion, Orac

  41. #41 Fernando Leiria
    July 28, 2008

    THANKS for your explantion, Orac

  42. #42 Fernando Leiria
    July 28, 2008

    THANKS for your explantion, Orac

  43. #43 Fernando Leiria
    July 28, 2008

    THANKS for your explantion, Orac

  44. #44 Fernando Leiria
    July 28, 2008

    THANKS for your explantion, Orac

  45. #45 Fernando Leiria
    July 28, 2008

    THANKS for your explantion, Orac

  46. #46 Fernando Leiria
    July 28, 2008

    THANKS for your explantion, Orac

  47. #47 Fernando Leiria
    July 28, 2008

    THANKS for your explantion, Orac

  48. #48 synapse
    July 29, 2008

    @LocutusIX: A diet is only healthy if it provides enough micro- and macro-nutrients. It is harder to provide large amounts of macro-nutrients and calories on a vegan diet; that is why they are probably healthier for most people in developed, food-rich countries. However, if someone expends great amounts of energy or have problems absorbing food or nutrients, a vegan diet may not provide enough calories. I knew a woman who was a vegan and a hard-core environmentalist who had to temporarily turn vegetarian because between growing a good deal of her own food, walking everywhere, and breastfeeding a large infant, her weight fell to 122lbs, which is very unhealthy for a 6’3″ tall woman. (She returned to veganism after her child was weaned.) If Steve Jobs cannot absorb many calories or nutrients from the food he eats because of his surgeries, he needs to eat more calorie-dense foods.