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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 (20kg). Esophagogastroduodenoscopy showed gastric outlet obstruction and a stenotic pylorus with pinpoint opening (●" Fig.1a, ●" 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 thepinpoint pyloricopening were performed using both endoscopic and radiologic guidance (●" Fig.1b, ●" Fig.1c). During the first two sessions the dilations were performed with 6and 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.1d). At this stage it was decided to perform incision Fig.1 Complex pyloric stenosis caused by post-transplant lymphoproliferative disorder in a 16-yearold boy. a Stenotic pylorus with pinpoint opening. b Dilation using a through-the-scope and over-thewire balloon. c Fluoroscopic guidance of dilation. d Remaining fibrotic stenosis after several balloon dilations.

Endoscopic repair of complex pyloroduodenal stenosis resulting from post-transplant lymphoproliferative disorder