Doctors On Steve Jobs: Cancer Recurrence And Other Theories

Melissa Lafsky of Discover consulted with the same endocrinologist the WSJ spoke to yesterday, Michael Jensen of the Mayo clinic. Dr. Jensen provided more specifics on what might be wrong with Steve Jobs.

We’ve also added a lengthy theory written by an anonymous surgeon (see below). Jensen and the anonymous surgeon appear to have reached different conclusions. Both, however, suggest that Steve will likely be OK.

Dr. Jensen says most likely scenario, based on Steve’s history and his description of his condition, is that his cancer has returned.  If so, this news is not necessarily devastating, and the treatment could still be “simple and straightforward,” as Steve suggested.

Discover: “If a patient came to me with [Jobs’s] history, the two big questions that would come to mind are: 1) is this a [recurrent] tumour, and 2) was there sufficient pancreas removed with the original surgery that he’s gradually lost his ability to digest and absorb food,” says Michael Jensen, an endocrinologist and nutrition specialist at the Mayo Clinic College of Medicine.

“The third option, when you take out the pancreas and see weight loss like this, is that it’s diabetes,” Jensen says. “But this would be something so well-known and treatable, we would have heard about it. Just the fact that they didn’t say it was diabetes means it probably isn’t.”

Jensen estimates that the chances of tumour recurrence versus impeded digestion are 50-50. But Jobs’s claim that the problem is both a “hormone imbalance” that can be treated through “nutritional” means (both terms that rank high on the obfuscation and vagueness scales) raises some questions. If the second option on Jensen’s list is true, and the CEO’s pancreas is no longer making the enzymes he needs to digest food, the problem is in fact dietary—but not hormonal.

“The kind of hormonal imbalances [that are possible] in his case cannot be treated by simple nutritional intervention. If he’s undergoing simple nutritional treatment, then it wouldn’t be a hormone problem,” says Jensen.

While the contradiction remains unexplained, other physicians have raised plenty of possibilities, such as the tumour removal upsetting the balance of hormones like insulin and glucagon, which help control blood sugar levels, or somatostatin and gastrin, which aid digestion and other functions. But there’s a very real possibility that Jobs may once again have cancer.

If this worst-case scenario is true, it might not be devastating for Jobs. In all likelihood, the recurrence would be of the same islet tumour removed in 2004. A malignant islet tumour that recurs still isn’t as deadly as normal pancreatic cancer, and while it could eventually be fatal, an islet tumour recurrence “does not typically cause a rapid, severe [decline] if you can control the hormonal problems, which you usually can,” says Jensen.

And here’s an excerpt from the anonymous surgeon’s take. Read the full post here:

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 stabilised, so why is Jobs apparently looking worse now?

I emphasise 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, diarrhoea, 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 tumour, 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.

See Also: Endocrinologists: Steve Jobs’ Diagnosis (And Prognosis) Unclear

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