We have analyzed our experience with 90 consecutive patients who were operated on for parapneumonic empyema between 1981 and 1992. Patients whose empyema did not resolve with chest tube drainage were taken to the operating room. Nineteen patients had limited thoracotomy and drainage. Seventy-one patients had formal thoracotomy, debridement, pleurectomy, and decortication. We found that an age greater than 60 years, cardiac disease, end-stage renal disease, end-stage bronchitis, prolonged tube drainage, and immunosuppression are associated with increased morbidity and mortality. In those patients who do not respond well to a short course of chest tube drainage, we recommend early aggressive surgical approach, including formal thoracotomy and definitive treatment. This allowed for early discharge from the hospital without chest tubes or open draining wounds. In extremely ill patients, limited thoracotomy may be all that is safe or possible and usually suffices.