© 2018 The American Association for Thoracic Surgery Objective: We analyzed the Society of Thoracic Surgeons' Database to describe the results of surgical decortication. Methods: A review of patients undergoing pulmonary decortication, excluding hemothorax and malignancy, from 2009 to 2016 was performed. Preoperative factors, length of stay, discharge status, readmission, morbidity, and mortality were compared between open and video-assisted thoracoscopic surgery approaches. Multivariable models identified risk factors for morbidity and mortality. Results: Of 7316 patients undergoing decortication, 6961 (95.2%) had a primary diagnosis of empyema. Video-assisted thoracoscopic surgery was used in 4435 patients (60.6%) and increased during the study period. Median length of stay was 4 days (interquartile range, 2-7) preoperatively and 7 days (interquartile range, 5-11) postoperatively. Mortality occurred in 228 patients (3.1%). Complications occurred in 2875 patients (39.3%), and major morbidity occurred in 1138 patients (15.6%). Transitional care after discharge occurred in 1922 patients (26.3%). Readmission within 30 days occurred in 452 patients (8.7%). Compared with video-assisted thoracoscopic surgery, mortality, major morbidity, prolonged length of stay, and discharge to other than home were higher with thoracotomy. In multivariable analysis, age, estimated glomerular filtration rate less than 60, chronic obstructive pulmonary disease, body mass index, American Society of Anesthesiologists level, Zubrod score, and thoracotomy were associated with increased mortality, morbidity, discharge to transitional care, and prolonged length of stay. Each additional preoperative hospital day (up to 5 days) increased mortality. Readmission, major morbidity, prolonged length of stay, and discharge to transitional care were all higher when preoperative hospitalization extended beyond 5 days. Conclusions: Surgeons participating in the Society of Thoracic Surgeons General Thoracic Surgery Database perform decortication for parapneumonic empyema and pleural effusion with limited mortality despite substantial postoperative morbidity. Further study is required to describe selection criteria for video-assisted thoracoscopic surgery and determine indications for surgical intervention to reduce delays in operative intervention.