Endoscopic follow-up (FU) after colorectal surgery is indicated mainly for patients operated on for cancer who are at risk for metachronous adenomas and/or recurrent cancer. Despite published guidelines, there is both overuse and underuse of endoscopic surveillance, and many institutions continue to have their own follow-up regimens. Therefore, endoscopic FU of colorectal cancer (CRC) survivors remains controversial, and there are several open issues regarding its appropriateness, timing, duration, and cost-effectiveness. Endoscopic FU should allow diagnosis of early anastomotic recurrences and metachronous adenomas and/or cancer in CRC patients after curative surgery. While endoscopic surveillance of the colonic anastomosis does not have any proven benefit, patients with prior rectal cancer should undergo flexible sigmoidoscopy∈±∈endoscopic ultrasound at 3-6-month intervals for the first 3 years after resection, if not treated with neoadjuvant chemoradiation and mesorectal excision. All CRC survivors should undergo lifelong endoscopic FU to prevent metachronous CRCs, with surveillance colonoscopies at 1, 3, and 5 years after surgery and then every 5 years until the benefit is outweighed by comorbidity. Recently, it has been proposed that endoscopic FU should be tailored according to the personal risk of the individual CRC survivor, based on the presence or absence of synchronous adenomas at perioperative colonoscopy, the diagnosis of metachronous lesions during surveillance, and the features of both synchronous and metachronous adenomas. This strategy has been shown to be cost-effective, with a clear survival benefit for CRC survivors.
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