AbstractAlthough portacaval shunt has been amply demonstrated as providing effective therapy for the control of bleeding varices, it produces total diversion of portal flow with a high incidence of hepatic failure which, if not fatal, is frequently associated with encephalopathy. Various modifications of the portacaval shunt, physiologically a central shunt, are associated with the same immediate and delayed negative side effects as the standard end‐to‐side portacaval shunt. Numerous therapeutic modifications intended to lessen the incidence and severity of post‐shunt encephalopathy, such as limitation of protein intake, antibiotics, normalization of plasma amino acids, and modification of the gastrointestinal flora, are largely unsuccessful. Trials of adjuvant procedures such as arterialization of the portal vein and colon exclusion, as well as attempts to reduce the mortality rate of the first variceal hemorrhage by either prophylactic shunt or emergency portacaval shunt, have produced disappointing results in most instances. End‐to‐side portacaval shunt is not the therapeutic final solution. It may be indicated in the patient with intractable or severe ascites, in the presence of massive uncontrolled hemorrhage (an emergency situation), and to a very limited extent, in the presence of a few otherwise uncontrollable metabolic diseases such as hyperlipidemia. Ideally, one would prefer to restrict this operation to those patients who are destined to bleed from varices again.