All of the following are contraindications for highly selective vagotomy except:

A. Intractable duodenal ulcer disease.

DISCUSSION: Intractable peptic ulcer symptoms are a classic indication for highly selective vagotomy. Patients with gastric outlet obstruction often do poorly with highly selective vagotomy and develop recurrent ulceration. Highly selective vagotomy is not indicated for gastric ulceration. Heavy chain smokers often get recurrent peptic ulceration after highly selective vagotomy; therefore, vagotomy and antrectomy is indicated for them. Patients who experience long periods of perforation before exploratory laparotomy should receive either patch plus vagotomy or pyloroplasty or patch of the ulcer alone. Extensive operations, such as highly selective vagotomy, are usually not indicated in this acute setting.