Although recurrence rates following LE in carefully selected cases should be low, it is imperative that those that fail should be identified at the earliest opportunity. The aim is to provide a safety net for those who choose some degree of oncological ‘trade-off’ detecting recurrence at a presymptomatic stage. Preliminary evidence suggests that salvage surgery under these circumstances can have more favourable outcomes than traditionally reported and can be managed without recourse to multiviscera resection and offer acceptable rates of margin involvement [21]. There is however no real consensus on follow-up schedule after local excision of an ERC. Recurrences usually occur within the first 2 years after resection, so investigation should be rigorous in this time period. The Oxford protocol consists of follow-up in clinic and flexible endoscopy at 3-monthly intervals for 2 years, thereafter 6-monthly for up to 5 years. Pelvic MRI is performed at 3, 9 and 24 months postoperatively, and a CT of the chest, abdomen and pelvis is performed annually for 3 years. At present PET-CT is not routinely recommended but can be employed to resolve uncertainty if local recurrence is suspected on MRI or CT. Although not part of our protocol, CEA levels can be determined every 3–6 months for 2 years, then every 6 months for a total of 5 years in patients who are potential candidates for resection of isolated metastasis. Many institutions with enthusiasm and expertise for ERUS will use this instead of MRI with impressive results but without the reproducibility and valuable baseline reference images of MRI.

In case of ‘high-risk’ ERC or unexpected pT2 cancer, the patient should be offered ‘completion surgery’ or early salvage as it is usually referred to in the literature, if there are no extenuating circumstances. The term ‘completion surgery’ is preferable to ‘salvage’ which has a negative connotation, and the patient must understand that the TEM specimen is an excisional biopsy and that further treatment (completion of therapy) may be necessary. Furthermore, data from the literature suggests that completion surgery, i.e. anterior resection or abdominoperineal excision, can offer comparable oncological outcomes after TEM compared to radical surgery performed as a primary treatment [5, 22]. Thus, if adverse pathology is detected following TEM, completion surgery can be undertaken without compromising oncological excellence. However, certain technical issues may make radical surgery after TEM more difficult, and there is perhaps a tendency towards abdominoperineal resection rather than restorative anterior resection in cancer of the lower third. There is no consensus on the timing of completion surgery nor on the use of preoperative radiotherapy. In the authors’ practice, patients are usually not given neo-adjuvant radiotherapy, and surgery is performed when the TEM site has completely healed and the inflammation at the site has subsided. In patients with significant co-morbidities that preclude major abdominal surgery, completion surgery is of course not an option for ‘high-risk’ early rectal cancer or pT2 disease. For these patients, adjuvant radiotherapy is a reasonable option. There is no high-quality data in the literature regarding postoperative adjuvant radiotherapy; however, a report by Duek et al. hints at some benefit [23]. Twelve patients with T2 rectal adenocarcinoma who had undergone radiotherapy after TEM remained disease free after a median follow-up of 3 years, while a 50 % recurrence rate was seen in four patients who refused adjuvant treatment. Patients may also choose close follow-up with regular scanning and sigmoidoscopy as outlined above; however, they must be counselled and made clear that this is an oncological compromise.