Recent reports suggest that the distal splenorenal shunt does fulfill its physiological promises. The portal and the gastroesophagealsplenic areas are divided into separate "venous watersheds." As a result, varices are decompressed but portal hypertension is preserved. It should, therefore, have its greatest advantage for patients with the most severe impairment of hepatic reserve. In this evaluation, the procedure was considered the operation of choice for all shunt candidates who had a patent splenic vein. A series of 20 patients, 12 with Laënnec cirrhosis, seven with postnecrotic cirrhosis, and one with Wilson disease, survived shunting and were discharged from the hospital. One patient died of hepatic coma eight weeks after operation. If lengthy follow-up studies confirm its capacity to prevent hemorrhage, the distal splenorenal shunt may be the safest elective shunt operation for patients with cirrhosis.