Purposes <p>Pancreaticoduodenectomy (PD) requires division of the gastroduodenal artery (GDA). In patients with previous surgical interventions, such as post-esophagectomy patients, the blood flow of the GDA should be preserved. However, a systematic surgical strategy has not been established for these patients. This study aimed to clarify the safety of a strategic diagram for PD that requires special caution during the GDA division.</p> Methods <p>We retrospectively reviewed the records of patients who underwent PD at two hospitals between 2019 and 2023. All patients were evaluated for precise planning from the anatomical and oncological aspects after PD in the preoperative multidisciplinary team, including the radiologist.</p> Results <p>Among 340 cases, there were 9 in which there were serious concerns regarding GDA division due to ischemic organ failure after standard PD. Among the 9 patients, 8 underwent GDA-preserving PD or PD with revascularization or organ reconstruction. In all cases, curative resection was achieved, and no patients developed ischemia in the remnant organs. Major postoperative complications (Clavien–Dindo grade ≥ 3) occurred in 2 patients (22%). There was no mortality.</p> Conclusion <p>Ischemic organ failure occurs in 2.6% of patients undergoing PD. Our proposed flowchart may be useful for complete resection without organ ischemia.</p>