BACKGROUND AND STUDY AIMS: Double-balloon enteroscopy (DBE) has been proved to be effective for deep intubation of the small bowel. Patients with a Roux-en-Y enteroanastomosis and biliary problems have been a challenge in gastrointestinal practice because of the lack of endoscopic access to the biliary anastomosis. We report on the first case series of patients with Roux-en-Y anatomy who have been examined using DBE. PATIENTS AND METHODS: Between September 2005 and May 2006, 18 endoscopic retrograde cholangiography procedures were performed in 13 patients (median age 53, range 2 - 81 years) using the DBE technique at our hospital. Most of the cases (10/13) had had a liver transplant for primary sclerosing cholangitis. The Fujinon T-series DBE system was used in all cases. RESULTS: The entero-enteric anastomosis was reached easily in all 18 procedures, and the end of the Roux limb was reached in 17/18 procedures. The mean intubation time was 40 minutes (range 5 - 120 minutes). Adequate imaging was achieved in all but two cases, one of whom had a native papilla. Biliary stenting was performed in two patients, stent removal in three patients, and removal of a small stone in one patient. CONCLUSIONS: Endoscopic access and biliary cannulation in the setting of Roux-en-Y anatomy is safe and feasible using the new DBE system for enteral intubation. Adaptation of accessories would further improve the utility of the procedure.