What's wrong with Steve Jobs?

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:

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.