Patient presents with recurrent duodenal ulcer of 2.5 cm size, the procedure of choice -

This question is basically irrelevant in the first place itself as recurrences are very uncommon in the present era and if occur can be very effectively treated with antibiotics and anti-secretory drugs. Here in this question, it's not mentioned whether the recurrence is after an acid-reducing operation or simply after medications. Lets first take the case of recurrence after a previous acid reducing surgery (this is most probably what the examiner means by recurrent ulcer as this topic is described in quite a detail in Maingot's) Recurrence after a prior acid reducing surgery: The management of patients with recurrent ulcer disease after acid-reducing operations consists of antibiotics directed at H. pylori + treatment with an antisecretory medication + limitation of NSAID use, smoking cessation, and limitation of alcohol intake. Ulcer disease refractory to such treatment is unusual. If the ulcer persists for more than 3 months despite eradication of H. pylori and maintenance antisecretory therapy or the ulcer is associated with perforation, bleeding, or obstruction, the operation is indicated. The choice of operation for recurrent postoperative ulcer depends on the indication for initial operation & the operation performed previously. Since these ulcers have recurred despite prior peptic ulcer disease surgery and maximal medical therapy, surgery should be appropriately aggressive. Truncal vagotomy with antrectomy is the operation of choice. This is the procedure with the least recurrence rate. Recurrence after prior treatment by medications: If at all surgery is needed an operation with least morbidity is advised i.e. Highly selective vagotomy. Recurrent gastric ulcer:  Non-healing gastric ulcers despite antibiotics and antisecretory drugs should be viewed with suspicion for malignancy (Duodenal ulcers have no risk of malignancy) and thus distal gastrectomy is the recommended operation. Other surgical options are wedge resection with HSV. (Note HSV is of no use in Type I and Type IV ulcers as these are associated with acid hyposecretion)