Objective To investigate the efficacy of endoscopic stent placement for patients with Bismuth type Ⅳ hilar cholangiocarcinoma. Methods Data of 229 patients with unresectable Bismuth type Ⅳ hilar cholangiocarcinoma who successfully underwent endoscopic stent placement at the Department of Endoscopy, the Third Affiliated Hospital of Naval Medical University from January 2002 to January 2019 were retrospectively analyzed. Outcomes included clinical success rate, complication incidence, stent patency period and overall survival time. The patency of stents and overall survival time of patients were estimated by using the Kaplan-Meier method. The independent predictors for stent patency and overall survival of patients were analyzed by a multivariate Cox proportional regression model. Results The overall clinical success rate was 78.2% (179/229). The incidence of early cholangitis after endoscopic retrograde cholangiopancreatography was 20.5% (47/229). The median stent patency and overall survival time were 5.7 (95%CI: 4.8-6.7) months and 5.1 (95%CI: 4.2-6.0) months, respectively. Further multivariate Cox regression analysis showed that metal stent (P<0.001, HR=0.452, 95%CI: 0.307-0.666) and bilateral stents with bilateral angiography (P=0.036, HR=0.644, 95%CI: 0.427-0.971) were independent predictors of stent patency; total bilirubin>200 μmol/L (P=0.001, HR=1.627, 95%CI: 1.208-2.192), metal stent (P=0.004, HR=0.636, 95%CI: 0.467-0.866) and antitumor therapy (P<0.001, HR=0.439, 95%CI:0.308-0.626) were independent predictors of overall survival. Conclusion There is high incidence of cholangitis in patients with unresectable Bismuth type Ⅳ hilar cholangiocarcinoma treated with endoscopic stenting. Longer stent patency can be achieved with metal stent placement and bilateral drainage. In addition, metal stent for drainage and antitumor therapy can also help increase the survival benefit.