Do we have the guts to go? The abdominal compartment, intra-abdominal hypertension, the human microbiome and exploration class space missions

Do we have the guts to go? The abdominal compartment, intra-abdominal hypertension, the human microbiome and exploration class space missions

Can J Surg 2020;63(6):E581-E593 | Full Text | PDF

Andrew W. Kirkpatrick, MD, MHSc; Douglas R. Hamilton, MD, PhD; Jessica L. McKee, MSc; Braedon McDonald, MD; Paolo Pelosi, MD; Chad G. Ball, MD, MSc; Derek J. Roberts, MD, PhD; Paul B. McBeth, MD, MASc; Federico Coccolini, MD; Luca Ansaloni, MD; Bruno M. Peireira, MD, MHSc, PhD; Michael Sugrue, MD; Mark R. Campbell, MD; Edward J. Kimball, MD; Manu L.N.G. Malbrain, MD, PhD


Humans are destined to explore space, yet critical illness and injury may be catastrophically limiting for extraterrestrial travel. Humans are superorganisms living in symbiosis with their microbiomes, whose genetic diversity dwarfs that of humans. Symbiosis is critical and imbalances are associated with disease, occurring within hours of serious illness and injury. There are many characteristics of space flight that negatively influence the microbiome, especially deep space itself, with its increased radiation and absence of gravity. Prolonged weightlessness causes many physiologic changes that are detrimental; some resemble aging and will adversely affect the ability to tolerate critical illness or injury and subsequent treatment. Critical illness–induced intra-abdominal hypertension (IAH) may induce malperfusion of both the viscera and microbiome, with potentially catastrophic effects. Evidence from animal models confirms profound IAH effects on the gut, namely ischemia and disruption of barrier function, mechanistically linking IAH to resultant organ dysfunction. Therefore, a pathologic dysbiome, space-induced immune dysfunction and a diminished cardiorespiratory reserve with exacerbated susceptibility to IAH, imply that a space-deconditioned astronaut will be vulnerable to IAH-induced gut malperfusion. This sets the stage for severe gut ischemia and massive biomediator generation in an astronaut with reduced cardiorespiratory/immunological capacity. Fortunately, experiments in weightless analogue environments suggest that IAH may be ameliorated by conformational abdominal wall changes and a resetting of thoracoabdominal mechanics. Thus, review of the interactions of physiologic changes with prolonged weightlessness and IAH is required to identify appropriate questions for planning exploration class space surgical care.

L’humanité est à l’aube d’une nouvelle ère d’exploration spatiale, mais le risque de maladies et blessures graves pourrait restreindre de manière catastrophique le potentiel des voyages dans l’espace. L’être humain est un superorganisme vivant en symbiose avec son microbiote, dont la diversité génétique éclipse celle de l’hôte. Cette symbiose est essentielle : tout déséquilibre est associé à une dégradation de l’état de santé dans les heures suivant l’occurrence d’une blessure ou d’une maladie grave. Bon nombre de caractéristiques propres au vol spatial ont des répercussions négatives sur le microbiote; l’espace lointain présente des dangers particuliers en raison de l’exposition accrue au rayonnement et de l’absence de gravité. L’exposition prolongée à l’apesanteur cause une myriade de changements physiologiques nuisant à la santé. Certains ressemblent à des processus de vieillissement et réduiront la capacité à tolérer une blessure ou une maladie grave et son traitement. L’hypertension intra-abdominale (HIA) causée par une maladie grave peut réduire la perfusion des viscères et du microbiote, ce qui peut avoir des conséquences catastrophiques. Des études sur modèle animal ont confirmé les effets profondément délétères de l’HIA sur les intestins par l’apparition d’une ischémie et une altération de la barrière intestinale; cette découverte permettrait d’établir un lien mécanistique entre l’HIA et la défaillance d’organes résultante. Par conséquent, une dysbiose pathologique, associée à un dysfonctionnement immunitaire en apesanteur et à une réduction de la réserve cardiorespiratoire accompagnée d’une exacerbation de la susceptibilité à l’HIA, pourrait signifier qu’un astronaute exposé à l’effet déconditionnant de l’apesanteur serait vulnérable aux problèmes de perfusion de l’intestin découlant de l’HIA. Ce problème pourrait à son tour mener à une ischémie intestinale grave et à une production massive de biomédiateurs chez un astronaute présentant déjà une capacité cardiorespiratoire et immunitaire réduite. Heureusement, des expériences dans des environnements simulant l’apesanteur semblent indiquer que les effets de l’HIA pourraient être contrés par des changements conformationnels de la paroi abdominale et un rétablissement de la mécanique thoracoabdominale. Par conséquent, un examen des interactions des changements physiologiques associés à un état d’apesanteur prolongé et à l’HIA est requis pour déterminer les questions à poser afin de planifier adéquatement les soins chirurgicaux en contexte d’exploration spatiale.

The material discussed in this manuscript was previously presented at the 9th Scientific Meeting of the Abdominal Compartment Society, in Campinas, Brazil, May 31, 2019.

Accepted Jan. 23, 2020

Affiliations: From the Tele-Mentored Ultrasound Supported Medical Interventions (TMUSMI) Research Group Collaborators; Departments of Medicine and Engineering, University of Calgary, Calgary, Alta. (Kirkpatrick, Hamilton, McKee); the Departments of Critical Care Medicine and Medicine, Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alta. (MacDonald); the Department of Surgical Sciences and Integrated Diagnostics, University of Genoa; Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy (Pelosi); Regional Trauma Services; Departments of Surgery and Critical Care Medicine, University of Calgary, Calgary, Alta. (Ball); the Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ont. (Roberts); the Tele-Mentored Ultrasound Supported Medical Interventions (TMUSMI) Research Group Collaborators; Regional Trauma Services; Foothills Medical Centre; Departments of Engineering, Surgery and Critical Care Medicine, University of Calgary, Calgary, Alta. (McBeth); the Departments of Trauma and Emergency Surgery, Pisa University Hospital, Pisa, Italy (Cocolini); the Departments of General, Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy (Ansaloni); the Division of Trauma Surgery, University of Campinas, Campinas, São Paulo, Brazil (Peireira); the Department of Surgery, Letterkenny University Hospital, Letterkenny, Donegal, Ireland (Sugrue); the Paris Regional Medical Centre, Paris, Texas, United States (Campbell); the Departments of Surgery and Critical Care, Network Development and Telehealth, University of Utah, Salt Lake City, US (Kimball); the Faculties of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium (Malbrain).

Competing interests: Major Andrew W. Kirkpatrick discloses having consulted for the Innovative Trauma Care and Acelity Corporations, and to having a personal relationship with J.L. McKee. Douglas R. Hamilton reports no disclosures. Jessica L. McKee discloses being employed by the Innovative Trauma Care Corporation. She has consulted for the Asceso, Sam Medical, and the Acelity Corporations. She has also done project work for the Canadian Forces and the COOL study. Her current position with the University of Calgary is funded through a grant with Purdue University. Braedon MacDonald reports no disclosures. Paolo Pelosi reports no disclosures. Chad G. Ball is coeditor-in-chief of CJS. He was not involved in the review or decision to accept this manuscript for publication. Michael Sugrue discloses payment for educational activity with Smith and Nephew, Acelity and NovusScientific that are not relevant to this paper Edward J. Kimball discloses that he is the current president of the World Society of the Abdominal Compartment. Manu L.N.G. Malbrain discloses that he is a member of the medical advisory boards of Pulsion Medical Systems (now fully integrated in Getinge, Solna, Sweden) and Serenno Medical (Tel Aviv, Israel), and that he consults for Baxter, Maltron, ConvaTec, Acelity, Spiegelberg and Holtech Medical. Derek Roberts, Paul B. McBeth, Federico Cocolini, Luca Ansaloni, Bruno Peireira and Mark R. Campbell report no disclosures.

Disclaimer: The opinions, interpretations, conclusions and recommendations are those of the authors only and are not specifically endorsed by Department of National Défense of Canada, or any other public or governmental agencies.

Funding: This work was partially supported by a Near Earth Space Technologies Grant from the University of Calgary.

Contributors: Andrew Kirkpatrick, Jessica McKee, Paolo Pelosi, Chad Ball, Derek Roberts, Paul McBeth, Luca Ansaloni and Manu Malbrain conceived and designed the study. Andrew Kirkpatrick and Chad Ball acquired the data and analyzed/interpreted it with Douglas Hamilton, Braedon MacDonald, Paolo Pelosi, Derek Roberts, Paul McBeth and Michael Sugrue. Andrew Kirkpatrick, Chad Ball, Paolo Pelosi, Derek Roberts, Paul McBeth, Edward Kimball and Manu Malbrain wrote the article. All authors critically revised the manuscript and gave final approval of the version of the article to be published.

DOI: 10.1503/cjs.019219

Correspondence to: AW Kirkpatrick, EG23 Foothills Medical Centre, Calgary, AB T2N 2T9,