OBJECTIVE The appropriate type of intervention for the treatment of empyema in children remains controversial. This study analyzed whether video-assisted thoracoscopic debridement (VATD) as first-line treatment is effective in the management of pediatric parapneumonic empyema. METHODS We retrospectively reviewed the medical and microbiological records of pediatric patients with parapneumonic empyema diagnosed at a medical center from January 1995 to December 2002. The 55 patients included in this study were initially treated with either tube thoracostomy drainage (TTD group [n = 37]) or video-assisted thoracoscopic debridement (VATD group [n = 18]). RESULTS A comparative analysis found no significant difference in patient characteristics between these 2 groups. Patients in the VATD group had a significantly shorter duration of fever (18.9 +/- 1.7 vs 26.9 +/- 1.3 days), chest tube placement (5.3 +/- 0.7 vs 15.2 +/- 2.0 days), antibiotic therapy after the procedure (12.2 +/- 1.0 vs 26.3 +/- 2.8 days), and hospital stay (21.5 +/- 2.1 vs 33.2 +/- 2.8 days). No additional procedures were required in the VATD group, whereas 65% (24/37) of patients in the TTD group underwent salvage VATD. CONCLUSIONS Primary management using video-assisted thoracoscopic decortication was more effective and reduced the duration of illness in pediatric patients with parapneumonic empyema.