Ventriculoperitoneal shunt (VPS) placement is a common neurosurgical procedure performed for the treatment of hydrocephalus. Patients requiring VPS due to acute stroke, intracerebral hemorrhage, or trauma often require enteral access as a result of their neurologic injury. Percutaneous endoscopic gastrostomy (PEG) placement is the most commonly utilized method of enteral access in these patients. VPS and PEG are often performed in a staged manner to minimize the risk of VPS infections. This study investigates what effect the order of VPS and PEG procedures has on the outcomes of patients requiring both. From a retrospective review of 749 patients who underwent PEG placement at a single institution between January 2002 and June 2007, patients who underwent both PEG and VPS were identified. Information regarding the order and timing of the two procedures, VPS complications, PEG complications, and demographic information were recorded. Results were analyzed using chi square test.Fifty-six (7.5%) patients underwent PEG and VPS. Nineteen (34%) patients underwent VPS prior to PEG (VP-PEG). Thrity-seven (66%) underwent PEG prior to VPS (PEG-VP). Number of days between procedures ranged from 5 to 414 (mean= 41 days) for the VP-PEG group and from 5 to 1080 (mean=75 days) for the PEG-VP group. VPS complications occurred in 2/19 (10.5%) of patients undergoing VP-PEG and 6/37(16.2%) of PEG-VP patients (p=0.56). CSF infection rates were 1/19 (5.3%) in the VP-PEG group and 2/37(2.7%) in the PEG-VP (p=0.62). The CSF infections in both groups were treated with antibiotics alone without shunt revision.In the VP-PEG group one patient required proximal shunt revision for clogged shunt. In the PEG-VP group, 5 patients developed obstruction, 4 required proximal shunt revision and one patient required revision of the abdominal portion of the shunt. PEG-related complications occurred in 0/19 of the VPS-PG group and 2/37 (5.4%) of the PEG-VP group (p=0.30). Both of these patients had intolerance to gastric feeds.VPS and PEG may be safely performed in the same patient. When this is the case, the incidence of PEG complications and VP-shunt complications is similar to the reported incidence of these complications when either procedure is performed alone. Additionally, the order of the procedures does not appear to impact outcomes and complications for either the shunt or the PEG.