Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice in patients unable to eat owing to neoplastic or neurological diseases. In a few cases, however, PEG is not feasible and on such occasions a surgical gastrostomy (SG) proves mandatory to prevent starvation. The aim of the present study was to evaluate the cases submitted to SG when PEG could not be performed and to compare the results of the two procedures. We reviewed the medical records of 52 patients who required clinical nutrition in the years 2000-May 2007: 41 cases underwent PEG and 11 SG. Surgery was adopted when PEG failed or was deemed not to be feasible Analysis of the two series included sex, age, indications, associated diseases, mortality, complications, hospital stay and survival. Head and neck malignancies were the main indication to SG (81.1%), while PEG was adopted mainly for neurological diseases. In two cases, SG was required after failure of PEG due to lack of transillumination. A tracheostomy was present in 54.4% of the SG group and in 17% of the PEG group. Thirty-day mortality was nil in SG and 12% in PEG; morbidity was 9 and 7.3%, respectively. Hospital stay was 7 days in SG and 3 days in the PEG group. Survival at 24 months was poor in both series: 10% in SG and 25% in PEG. In case of PEG failure or contraindication, SG is more than satisfactory in terms of effectiveness, mortality and morbidity.