Is there any role for surgical decompression in treating variceal bleeding? This question is frequently asked because there are now many other options. Pharmacologic and endoscopic therapies are optimal first-line treatments, TIPS has been widely applied to decompress portal hypertension, and liver transplantation for end-stage liver disease is used to treat a significant number of patients with variceal bleeding. The authors of this article show that for a population of patients in the Pacific Islands, surgical decompression of varices provided good therapy for variceal bleeding.