A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether video-assisted thoracic surgery (VATS) is the best treatment for paediatric pleural empyema. Altogether 274 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that early VATS (or thoracotomy if VATS not possible) leads to shorter hospitalisation. The duration of chest tube placement and antibiotic use is variable and does not correlate with treatment method. Patients who underwent primary operative therapy had a lower aggregate in-hospital mortality rate (0% vs. 3.3%), re-intervention rate (2.5% vs. 23.5%), length of stay (10.8 days vs. 20.0 days), duration of tube thoracostomy (4.4 days vs. 10.6 days), and duration of antibiotic therapy (12.8 days vs. 21.3 days), compared with patients who underwent non-operative therapy. Similar complication rates were observed for the two groups (5% vs. 5.6%). Moreover, median hospital charges for VATS were $36,320 [interquartile range (IQR), $24,814-$62,269]. The median pharmacy and radiological imaging charges were $5884 (IQR, $3142-$11,357) and $2875 (IQR, $1703-$4950), respectively, for VATS and tube drainage. Adjusting for propensity score matching, costs for primary VATS were equivalent to primary chest tube placement. Only one article found discordant results. Ninety-five children (52%) received antibiotics alone, and 87 (45%) underwent drainage procedures (21 chest tube alone, 57 VATS/thoracotomy, and eight chest tube followed by VATS/thoracotomy); only four received fibrinolytics. Mean (standard deviation) length of stay was significantly shorter in the antibiotics alone group, 7.0 (3.5) days vs. 11 (4.0) days. The strongest predictors of undergoing pleural drainage were admission to the intensive care unit and large effusion size (>1/2 thorax filled).