Introduction: In 2001, a liver transplantation program was commenced at Tehran University of Medical Sciences as the first one in the capital city of Tehran and the second center in Iran. We are willing to report our experiences after 12 years of study in one of the well-established centers in the Middle East region. In addition, we want to find factors associated with improved outcomes, emphasis on how a liver transplantation program can be established, and move toward better outcomes.

Materials and Methods: One-hundred and seventy two deceased donor orthotopic liver transplantations were performed between 1/2002-2/2013. This period was divided into four phases based on technical advances and number of transplants performed per year: 2002 to 2005 (n=9), 2006 to 2009 (n=41), 2010 to 2011 (n=49), and 2012 to 2013 (n=73). The prospectively recorded data of the liver recipients were assessed during different phases.

Results: Viral hepatitis was the most underlying liver disease (26%) followed by autoimmune hepatitis (23%) and cryptogenic cirrhosis (23%). The number of liver transplantations increased to more than 50 per year. In the end of phase two, after 50 liver orthotopic liver tranplantations, the learning curve was completed. Mean cold ischemia time (800 vs. 289 minutes, P<0.001), operative time (600 vs. 313 minutes, P<0.001) and transfusions of intraoperative platelet (8.75 vs. 0.53 units, P<0.001), packed red blood cell (11.4 vs. 5 units, P<0.001), and fresh frozen plasma (12.7 vs. 0.4 units, P<0.001) were decreased significantly over the time. Post transplant complications were not significantly differed from two to phase four: acute rejection (29% vs. 35%, P=0.73), hepatic artery thrombosis (12% vs. 4%, P=0.78) , and infection (49% vs. 45%, P=0.42). Overall, the most cause common of death was sepsis followed by intraoperative and postoperative bleeding. The short- and long-term patient survival rates increased significantly: 3-month patient survival rate improved from 44% to 95% (P<0.001) and 1-year patient survival improved from 33% to 88% (P<0.001).

Conclusions: Important factors to develop a new liver transplantation program and improve the outcomes are forming a cooperative multidisciplinary team, managerial coordination of different units, overcoming the learning curve and continuous modification of anesthesia and surgical techniques. In addition, comprehensive unified written protocols for every detail of pre, peri, and post transplant medical and surgical care can lead to better outcomes even after completing the learning curve.