Therapy of variceal bleeding is currently based on endoscopic sclerotherapy. However, the treatment of bleeding recurrences after sclerotherapy has not yet been established, but consists of the choice between continuation of sclerotherapy or a surgical procedure. We report herein the results of portocaval shunt performed in 26 cirrhotic patients among the 175 cirrhotic patients (15%) admitted between 1985 and 1990 to our Intensive Care Unit for variceal bleeding. These 26 patients were operated because of failure of sclerotherapy as defined by haemostasis failure (n = 1), the persistence of unchanged oesophageal varices after six sessions of sclerotherapy (n = 1), and the occurrence of at least one severe episode of rebleeding (n = 24). Emergency and elective portocaval shunts were performed in 12 and 14 cases respectively. The time delay between admission and surgical procedure was equal to 21 +/- 8 hours and 12 +/- 4 days in the two groups respectively. The operative mortality (30 days) was equal to 23% and was observed in emergency shunts only. Actuarial survival rates were significantly different between the two groups (p < 0.01). Predictive factors of mortality as assessed by univariate analysis were the emergency nature of the procedure, serum aminotransferases and urea levels at the time of the index bleeding, and the number of bleeding episodes related to portal hypertension before the index bleeding. The prognosis at one year was not influenced by the number of bleeding recurrences between the index bleeding and the bleeding episode justifying the shunt.(ABSTRACT TRUNCATED AT 250 WORDS)