Pericardial effusion is a clinically significant condition characterized by the pathological accumulation of fluid within the pericardial cavity, which normally contains approximately 10–50 mL of serous fluid that facilitates cardiac motion [1]. The etiology of pericardial effusion is diverse and includes inflammatory and non-inflammatory causes such as malignancy, infection, autoimmune disorders, trauma, renal failure, and post-cardiac surgical states [1,2]. Although some patients remain asymptomatic, progressive fluid accumulation may result in cardiac tamponade, a life-threatening condition associated with hemodynamic instability and increased mortality if left untreated [2,3].

Management strategies depend on the etiology, severity, and hemodynamic consequences of the effusion. Pericardiocentesis is widely considered the first-line intervention in emergent settings because of its minimally invasive nature and high immediate success rate [4]. However, recurrence remains common, particularly in malignant or chronic effusions, often necessitating more definitive surgical drainage approaches [4,5].

Surgical pericardial window creation has emerged as a reliable technique for continuous drainage and prevention of recurrent fluid accumulation, especially in recurrent, loculated, or malignant effusions where percutaneous drainage may be insufficient [6]. Several surgical techniques have been described, most notably Pleuropericardial window (PLW) and Pericardioperitoneal window (PPW) procedures.

The Pleuropericardial approach establishes communication between the pericardial and pleural cavities and has demonstrated favorable perioperative outcomes and low recurrence rates in both open and thoracoscopic settings [7,8]. Minimally invasive thoracoscopic Pleuropericardial window techniques have also been associated with shorter hospital stay, rapid recovery, and low postoperative morbidity [8]. Similarly, studies comparing subxiphoid and thoracoscopic approaches have suggested that pleural-based drainage may provide effective long-term symptom relief with acceptable safety profiles [9].

The Pericardioperitoneal window procedure offers an alternative drainage route into the peritoneal cavity and may be particularly useful in recurrent or refractory effusions [10]. Previous reports have demonstrated durable symptomatic improvement and satisfactory recurrence prevention in selected patients with malignant pericardial effusion [10,11]. In addition, combined Pleuropericardial and Pericardioperitoneal approaches have been described in highly selected refractory cases with acceptable procedural outcomes [12].

Despite these promising findings, comparative evidence directly evaluating PPW and PLW remains limited. Most published literature consists of case reports, small retrospective series, or studies comparing surgical drainage with pericardiocentesis rather than direct comparisons between surgical techniques [5,9]. Furthermore, the rarity of these procedures and variability in patient selection continue to limit the development of standardized evidence-based recommendations. Given these gaps in the literature, this study aimed to perform a retrospective exploratory analysis comparing perioperative outcomes between Pleuropericardial and Pericardioperitoneal window procedures at Jordan University Hospital. By evaluating complications, recurrence, perioperative recovery parameters, and mortality, this study seeks to provide rare regional comparative data that may contribute to future multicenter investigations and guide individualized surgical decision-making.

Surgical pericardial window creation remains an important therapeutic option for recurrent or clinically significant pericardial effusion, particularly in patients with recurrent malignant effusion or failed percutaneous drainage [4,5]. Both pleuropericardial and pericardioperitoneal techniques have demonstrated acceptable safety profiles in previous reports, although direct comparative evidence remains limited.

In this exploratory cohort study, no statistically conclusive differences were identified between PPW and PLW procedures regarding early postoperative complications or acute perioperative outcomes. These findings are broadly consistent with previous literature suggesting that perioperative differences between surgical drainage techniques may be modest [8,9].

Although not statistically significant, PLW demonstrated numerically shorter ICU stay, hospital LOS, chest tube duration, and lower estimated blood loss. While these findings should not be interpreted as evidence of procedural superiority, they may suggest potential practical advantages of pleural drainage pathways in selected patients, particularly regarding postoperative recovery and chest tube management. Even modest reductions in ICU utilization, hospitalization, or drain duration may carry clinically meaningful implications in high-risk or resource-limited settings. These findings remain hypothesis-generating and require confirmation in adequately powered prospective studies.

The primary outcome of early postoperative complications occurred more frequently in the PLW group. However, the estimates were highly imprecise because of the small sample size and wide confidence intervals. In addition, PLW patients demonstrated higher BMI values and greater prevalence of certain comorbidities, suggesting possible baseline imbalance and confounding by indication.

Long-term durability remains one of the most clinically important considerations when selecting a surgical drainage strategy. Previous studies comparing surgical drainage with pericardiocentesis have reported lower recurrence rates with surgical window creation but increased procedural invasiveness and bleeding risk [5,6]. Similarly, minimally invasive thoracoscopic approaches have demonstrated favorable recurrence prevention and recovery outcomes in selected patients [7-9].

However, long-term outcomes in the present study could not be reliably assessed because of incomplete follow-up documentation. Follow-up duration was documented for only one patient, and mortality data were available for only half of the cohort. Consequently, recurrence, survival, and procedural durability could not be adequately evaluated.

An additional limitation is the prolonged study period spanning 25 years. During this interval, perioperative management, imaging modalities, anesthetic techniques, ICU care, and surgical practices likely evolved substantially. These temporal changes may have introduced confounding that could not be adequately controlled because of the retrospective design and limited cohort size [13-16].

Despite these limitations, this study represents one of the few regional comparative analyses evaluating PPW and PLW procedures within a single institutional cohort. Structured data cleaning, standardized outcome reporting, and transparent statistical interpretation improved methodological consistency and reporting quality.

Several limitations should be acknowledged. First, the retrospective single-center design introduces potential selection bias and residual confounding. Second, the small sample size limits statistical power and precision. Third, incomplete follow-up significantly restricted interpretation of long-term outcomes. Fourth, baseline differences between groups may have influenced perioperative outcomes. Finally, the prolonged inclusion period may have introduced temporal heterogeneity in perioperative care [16-20].

Overall, this exploratory study did not identify statistically conclusive superiority of either procedure. Numerical trends favoring PLW in several perioperative recovery parameters warrant further investigation in larger prospective multicenter cohorts.

In this retrospective exploratory cohort study, no statistically conclusive differences were identified between pericardioperitoneal and pleuropericardial window procedures regarding early postoperative outcomes. Although the pleuropericardial approach demonstrated numerically shorter hospital and ICU length of stay, shorter chest tube duration, and lower estimated blood loss, these findings were not statistically definitive.

Interpretation of the results is limited by the retrospective single-center design, small sample size, baseline imbalance between groups, temporal heterogeneity across the study period, and incomplete long-term follow-up. Both PPW and PLW appear to represent clinically acceptable surgical approaches for the management of pericardial effusion, and procedural selection should remain individualized according to patient characteristics, underlying pathology, anatomical considerations, and surgical expertise. Further prospective multicenter studies with larger sample sizes and standardized follow-up are required to better evaluate comparative safety, recurrence risk, and long-term procedural durability.

The study protocol was approved by the Institutional Review Board (IRB) of Jordan University Hospital. The requirement for informed consent was waived because of the retrospective nature of the study. Patient confidentiality was maintained through anonymization and secure handling of extracted data.

None

None

None

The views expressed in the submitted article are the author's own and not an official opinion of the institution or funder.

No Funding

Ethical approval was obtained from Jordan University Hospital IRB, code: 10/2025-27514

No Closed involvement