The recurrence rate after highly selective vagotomy was evaluated in patients with chronic duodenal ulcer disease presenting non-refractory (64 cases) or refractory ulcers (41 cases) followed for 1 to 8 years postoperatively. Refractoriness was considered when an ulcer remained symptomatic and was not healed at endoscopy after 8 weeks (3 cases) or 12 weeks (30 cases) of appropriate treatment with cimetidine, or when it recurred during maintenance therapy and did not heal after adapted treatment (8 cases). The cumulative 5 year-recurrence rate was 28.7% in refractory ulcers, in contrast with 9.3% in non-refractory ulcers (p less than 0.05). The early and constantly increased risk of recurrences in the refractory ulcer group could not be explained by factors related to surgeon or technique, nor by differing patient characteristics, including sex, age at the first ulcer episode, duration of the preoperative ulcer disease, familial ulcer history, prior ulcer complications, use or abuse of anti-inflammatory drugs, caffeine or alcohol, smoking habits and occupational state. It is concluded that highly selective vagotomy can not be considered a surgical procedure of choice in patients with refractory duodenal ulcers as there are valuable alternatives.