Objective To determine a better treatment and endoscopic stent for type Ⅳ hilar cholangiocarcinoma. Methods Clinical data of 65 patients diagnosed with type Ⅳ hilar cholangiocarcinoma at Department of General Surgery, the First Hospital of Lanzhou University from September 2010 to September 2018 were retrospectively analyzed. According to different endoscopic drainage methods, the patients were divided into three groups, endoscopic retrograde biliary drainage (ERBD) group (n=38), ERBD + endoscopic metal biliary endoprosthesis (EMBE) group (n=23) and EMBE group (n=4). According to different contrast methods, patients were divided into the contrast media group (n=26), air contrast group (n=22) and non-contrast group (n=17). Incidence of postoperative acute cholangitis, incidence of bilirubin levels decline and in-hospital mortality were analyzed. Results The incidences of acute cholangitis in ERBD group, ERBD+EMBE group and EMBE group were 23.7% (9/38), 52.2% (12/23) and 75.0% (3/4), respectively, with significant differences (χ2=7.499, P=0.006). The in-hospital mortalities of the above three groups were 5.3% (2/38), 13.0% (3/23) and 50.0% (2/4), respectively, with significant differences (χ2=7.729, P=0.021). For pairwise comparisons, there was significant difference in in-hospital mortalities between ERBD group and EMBE group (χ2=8.406, P=0.004). The incidences of acute cholangitis were 57.7% (15/26), 27.3% (6/22) and 17.6% (3/17), respectively, in the contrast media group, the air contrast group and the non-contrast group, with significant difference (χ2=8.407, P=0.015). For pairwise comparisons, there was significant difference in acute cholangitis incidence between the contrast media group and the non-contrast group (P=0.012). Conclusion For type Ⅳ hilar cholangiocarcinoma, biliary double plastic stent implantation can significantly reduce the incidence of postoperative acute cholangitis and the mortality during hospitalization, which can be used as the preferred stent scheme. Additionally, intraoperative contrast agents may increase the incidence of postoperative acute cholangitis which should be used with caution.