We report on our experience with a modified version of the distal splenorenal shunt (DSRS) initially described by Warren. Since 1976 more than 150 shunts have been done in the department. The first part of this study shows the long-term results of a series of 100 consecutive patients treated electively. The estimated survival at 80 months was around 30%. On the other hand, the median survival rate (68 months) and the five-year survival (52%) of Child's A patients differed significantly from those of Child's B patients (8 months and 15%, respectively). These results suggested that the modified DSRS was an effective and relatively safe procedure for the elective treatment of variceal bleeding and warranted a prospective and randomized trial to compare DSRS and endoscopic sclerotherapy (ES). In the second part of the study, in which ES was compared with DSRS, both modalities showed a similar survival rate, although patients in the DSRS group had a higher incidence of encephalopathy and patients in the ES group were more prone to rebleed. It was concluded that ES was a good alternative to DSRS for the elective treatment of esophageal variceal bleeding. If orthotopic liver transplant is considered the only definitive mode of treatment for the elective management of portal hypertension, the DSRS should be reserved for patients in whom ES has not been totally effective, or varices are located predominantly in the fundus of the stomach.