Post-transplant lymphoproliferative disorder (PTLD) is a serious complication after
solid organ or allogeneic hematopoietic stem cell transplantation with an incidence
rate up to 11 % [1].
While PTLD rarely affects the gastrointestinal (GI) tract [2], in the reported cases it may affect any part of the GI tract, sometimes resulting
in stenosis and obstruction [3].
We present here the case of a 16-year-old boy who had undergone double solid organ
transplant, namely a heart transplant at 4 weeks of life because of tricuspid atresia
and kidney transplant at 14 years of age because of end-stage kidney injury from calcineurin
inhibitors. In June 2013 he developed PTLD that was treated with rituximab for 18
months. However 1 month after the end of the rituximab treatment, the patient presented
with vomiting and massive weight loss (20 kg).
Esophagogastroduodenoscopy showed gastric outlet obstruction and a stenotic pylorus
with pinpoint opening ([Fig. 1 a], [Video 1]). Given the history of PTLD and the patient’s poor general status, surgical advice
ruled out performance of a gastrojejunostomy and the patient was referred to our unit
for a second opinion. An endoscopic solution was offered. Initially, gradual dilations
of the pinpoint pyloric opening were performed using both endoscopic and radiologic
guidance ([Fig. 1 b], [Fig. 1 c]). During the first two sessions the dilations were performed with 6- and 8-mm biliary
dilation balloons, respectively (Cook, Bloomington, Indiana, USA). Subsequent dilations
were performed at 2 – 3-week intervals using larger controlled radial expansion balloons.
Despite this aggressive protocol the stenosis remained tight and the patient remained
partially symptomatic. The lumen of the stenosis had increased in diameter, but the
ring was fibrotic ([Fig. 1 d]). At this stage it was decided to perform incision and resection of the fibrotic
ring using an insulated-tip (IT)-knife (Olympus, USA) ([Fig. 2 a]). This resulted in permanent opening of the pylorus. The patient remained asymptomatic
and with adequate intake at 9-month follow-up ([Fig. 2 b]).
Fig. 1 Complex pyloric stenosis caused by post-transplant lymphoproliferative disorder in
a 16-year-old boy. a Stenotic pylorus with pinpoint opening. b Dilation using a through-the-scope and over-the-wire balloon. c Fluoroscopic guidance of dilation. d Remaining fibrotic stenosis after several balloon dilations.
Complex pyloric stenosis caused by post-transplant lymphoproliferative disorder in
a 16-year-old boy: endoscopic management.
Fig. 2 a Resection of pyloric stenosis using an insulated-tip (IT)-knife. b Appearance at 9-month follow-up after IT-knife resection.
This report is of interest for several reasons. First we present a complication after
solid organ transplant, showing that PTLD may lead to gastric outlet obstruction.
Second, we show that a staged and graduated endoscopic approach may lead to resolution
of this complex gastric outlet obstruction. And finally, we demonstrate that the IT-knife
can be used efficiently to perform endoscopic resection of a fibrotic pyloric ring.
Although the IT-knife was designed to perform endoscopic submucosal dissection, its
ceramic tip and short-ended wire appear to be nicely suited to performance of resection
of fibrotic rings of the luminal GI tract.
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