Purpose: Data suggest that gastroenterologists perform surveillance colonoscopy more often than recommended by guidelines. This practice may be driven by medico-legal concerns over missed cancers. Though more frequent colonoscopy may reduce the risk of missed cancers, it also increases the risk of procedure-related complications. According to malpractice data, such complications, particularly colonic perforation, are the most common reason for litigation against gastroenterologists. Yet, no study has compared the frequency of missed cancers and colonic perforations in patients undergoing “intensive” vs recommended colonoscopic surveillance. Methods: We developed a Markov model to determine the number of opportunities for litigation in a cohort of 1000 men/women ≥50 yrs of age with a new diagnosis of colon adenomas. We modeled 2 surveillance strategies: (1) an “intensive” strategy with colonoscopy every 3 years in all patients; and, (2) a “recommended” strategy with colonoscopy every 3–5 yrs based on current guidelines. The base-case assumptions (and ranges for sensitivity analysis) were: (1) risk of colonic perforation: 0.25% (0.1%-0.4%); (2) relative risk of litigation due to missed cancer vs perforation: 1.0 (1.0–3.0); and, (3) advanced adenoma miss rate: 6% (0%-12%). Results: In the base-case analysis, the “intensive” strategy resulted in 46 opportunities for litigation over the lifetime of the cohort (22 perforations & 24 missed cancers). In contrast, the “recommended” strategy endorsed by current guidelines resulted in only 40 opportunities for litigation (14 perforations & 26 missed cancers). In sensitivity analysis, the number of opportunities for litigation under the “intensive” strategy was greater than under the “recommended” strategy even when the perforation rate was reduced (0.1%), when the relative risk of litigation due to an interval cancer was increased (3-fold), or when the advanced adenoma miss rate was increased (12%). Conclusion: Compared to the recommended strategy, more intensive surveillance is associated with slightly fewer missed cancers but substantially more colonic perforations, resulting in more opportunities for litigation. This result was robust to a wide range of assumptions in sensitivity analysis. Endoscopists who disregard current guidelines and perform more intensive surveillance out of concern for missed neoplasia should carefully weigh the competing risk of procedure-related complications.