Introduction: Intestinal transplantation (Itx) is the optimum and end-point treatment option for Intestinal failure which is a major life-threatening medical entity. However, today's international guidelines limit this complex procedure when less-invasive alternatives like home-based parenteral nutrition (HPN), autologous gastrointestinal reconstruction surgery, and entero-hormonal therapy fail. Considering some economic and technical barriers, HPN and medications such as Glucagon-like peptide 2 agonists are not available in Iran, we have tailored the indications and protocols to achieve the best outcome despite shortcomings.
Methods: Medical records of all Itx recipients at Shiraz Transplant Center, Shiraz, Iran in the period of 2006 to 2023 were retrospectively collected, analyzed, and reported. Intestinal autotransplantations were excluded.
Results: From the first Itx performed in 2006 to 2023, 78 Itx were performed at Shiraz Transplant Center. 56 cases died and 22 are alive. 39 (50%) were male and the mean age was 35.2 years. 38 cases underwent isolated Itx and the others were multi-visceral transplants.

Conclusion: Shiraz Intestinal Rehabilitation Unit is the largest center of its own kind in the Middle East. Lack of HPN in Iran advocated an earlier ITx, and less long-term parenteral nutrition which led to lesser HPN-related complications like hepatic failure and partially saving more lives by overcoming the limitation by customizing the protocols, however, the mortality is still remarkable and more equitable distribution of health facilities is needed.