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Context Parapneumonic effusion and empyema are commonly encountered by the pulmonologist. The decision regarding management is still challenging. Aim To compare outcomes of intrapleural streptokinase with pigtail catheter drainage versus medical thoracoscopy in complicated parapneumonic effusion. Methods and material Forty patients with complicated parapneumonic effusion were randomly allocated to one of two groups. Twenty patients underwent streptokinase intrapleural instillation via pigtail catheter. The other twenty patients underwent medical thoracoscopy. Results Intrapleural streptokinase instillation procedure was significantly shorter duration (12.80 ± 3.05 min) than medical thoracoscopy procedure (25.26 ± 4.66 min). However medical thoracoscopy showed a significant less days required to remove the drainage system (5.80 ± 1.70 days) versus intrapleural streptokinase instillation procedure (9.40 ± 3.91 days). Both groups had no significant complications. Lung expansion was achieved in 90% of patients treated with intrapleural streptokinase instillation and in 95% of patients treated with a medical thoracoscopy technique, with no statistically significant difference between the two groups. Conclusions Treatment of complicated parapneumonic effusions is undeniably interdisciplinary. Both intrapleural streptokinase with pigtail catheter drainage and medical thoracoscopy are safe and improve outcomes in complicated parapneumonic effusion. Medical thoracoscopy has an advantage of fewer days required for tube withdrawal. Pigtail insertion has an advantage of shorter procedure time compared to medical thoracoscopy [ABSTRACT FROM AUTHOR]