Background: Surgical treatment may be necessary in childhood chronic pleural empyema. Methods: Over a 21-year period 642 children with pleural empyema were hospitalized and 104 of them underwent surgical treatment. The records of the children who underwent surgery for the treatment of empyema were retrospectively reviewed to describe the role, indications, and results of surgical treatment of childhood chronic pleural empyema. Results: Etiologic diseases or conditions leading to empyema were pneumonia in 69 patients, tuberculosis in 13, hydatid cyst in eight, postpneumonectomy empyema in five, and other causes in nine patients. Indications for surgery were severe pleural thickening in 54 cases (51.9%), trapped lung in 36 cases (34.6%), loculated empyema in eight cases (7.7%) and bronchopleural fistula in six cases (5.8%). Operations performed were decortication in 90 patients, pulmonary resection and decortication in seven, muscle flap closure in five, and pneumonectomy in two. Success rates in the treatment of nonspecific and tuberculous empyema were 93% and 54%, respectively. Conclusions: Surgical treatment is still necessary in childhood pleural empyema in developing countries, and success rates are very high in nonspecific pleural empyema and acceptable in tuberculous pleural empyema.