Navigating the Terrain of Post-Polypectomy Surveillance: Charting the Complex Landscape of Guidelines and Recurrence Risks

Colorectal cancer (CRC) remains a leading cause of global cancer-related morbidity and mortality. The majority of CRC cases arise through two well-established pathways: the conventional adenoma–carcinoma sequence and the serrated neoplasia pathway. Colonoscopic polypectomy significantly reduces the incidence of CRC, yet postoperative recurrence rates remain substantial, underscoring the critical role of post-polypectomy colonoscopic surveillance (PPCS). Recent updates to PPCS guidelines by major gastroenterological societies—including the US Multisociety Task Force (USMSTF), European Society of Gastrointestinal Endoscopy (ESGE), British Society of Gastroenterology/Association of Coloproctology of Great Britain and Ireland/Public Health England (BSG/ACPGBI/PHE), and the Asia-Pacific Task Force—reflect evolving strategies for risk stratification and surveillance intervals. While all guidelines prioritize colonoscopy resources for high-risk populations and reduce burden for low-risk individuals, significant variations persist in definitions of high-risk adenomas (HRA), recommendations for surveillance intervals, and management of specific histological subtypes such as villous architecture. This review comprehensively compares these updated guidelines, highlighting consensus and discordance in clinical recommendations. Furthermore, it synthesizes evidence on multifactorial recurrence risks, encompassing baseline adenoma characteristics, patient-specific factors, and the quality of endoscopic procedures. Regarding the association with the same risk factor, traditional adenomas and serrated polyps may demonstrate heterogeneity. Understanding these elements is essential for optimizing personalized surveillance strategies and reducing recurrent adenoma burden. Finally, we hope that this review will provide decision-making support for countries lacking standalone guidelines and help clinicians navigate complex and contradictory guideline recommendations.