Analysis of changes in the pattern of portasystemic shunt surgery.Single centre retrospective study.University hospital, The Netherlands.74 patients receiving portasystemic shunts during a 15 year period, with complete follow up.Severity of disease, type of operation, early mortality, long term survival and development of encephalopathy.The number of portasystemic shunts undertaken during the study period declined, with a rise in the proportion of emergency operations. Early mortality was 1/38 (3%) in patients with Child A disease, 2/27 (7%) in those with Child B, and 5/9 (56%) in those with Child C (p < 0.0005, chi square). Early mortality was highest (p = 0.004, Fisher's exact test) after emergency operations with 6/20 (30%), compared with 2/54 (4%) following elective shunt surgery. The 5-year cumulative survival was 77% in patients with Child A, 58% in patients with Child B, and 11% in patients with Child C disease (p < 0.001, log rank). Survival was significantly less in patients with alcoholic liver cirrhosis (p < 0.05, log rank). Postoperative encephalopathy was treated clinically in 16/73 (22%) patients, and developed irrespective of the type of decompression.With the increasing importance of other treatments of portal hypertension and variceal haemorrhage the pattern of portasystemic shunt surgery has changed. Despite a steady decline in the number of elective decompressions, that of acute operations has been constant over the years. These procedures had a considerable early mortality. The severity of the liver disease was a strong determinant of long term survival, as was the presence of alcoholic liver cirrhosis. Postoperative encephalopathy was common and was independent of the shunt technique used. In elective cases portasystemic shunting techniques, that will not interfere with a subsequent hepatic transplantation, are preferred.