The results of conservative medical (propranolol) and endoscopic therapy for bleeding esophageal varices show that the surgical shunt is indicated in both, acute and elective situations. The portocaval end-to-side-shunt should be preferred for hemodynamic reasons. However, special selection of patients is required to prevent postoperative liver failure. Linton, Drapanas and Warren shunts have a higher recurrence rate, but seem more appropriate for liver transplantation candidates. In our own series, preoperative diagnostic shunt-simulation by balloon-occlusion of the portal vein via an umbilical catheter has tremendously improved the results, even for child C-patients.