<p>The prognostic impact of acute symptoms requiring surgery in patients with small-bowel neuroendocrine tumors (SB-NETs) remains debated. We assessed short- and long-term outcomes of SB-NETs according to the timing (elective versus acute) of surgery. We retrospectively evaluated all consecutive patients operated for SB-NETs between January 1, 1997 and June 30, 2023. Multivariate Cox analysis identified risk factors for survival. Patients were compared according to the timing of surgery. During the study period, 97 patients with SB-NETs underwent surgery. Surgery was performed in the acute setting in 18 patients (18.5%). Patients operated in acute setting were older (<i>p</i> = 0.03) and had less frequently mesenteric masses (<i>p</i> = 0.03), and synchronous metastatic disease (<i>p</i> = 0.0004) but more often occlusive bowel disease (<i>p</i> &lt; 0.0001) and had higher comorbidities load (AFC score) (2.5 ± 0.5 vs0.69 ± 0.8, <i>p</i> &lt; 0.0001). Patients operated in acute setting had a similar number of lymph nodes retrieved (<i>p</i> = 0.90), less node positive (<i>p</i> = 0.009) but had greater rate of reoperation (<i>p</i> = 0.005) and higher postoperative mortality (22% vs 0%; <i>p</i> = 0.009). Surgery in acute setting was not identified as a prognostic factor for tumor-related overall and disease-free survival. Surgery in acute setting for symptomatic tumors has a negative impact on short outcomes of patients with SB-NETs but does not impact long-term survival. Because of higher mortality of surgery for symptomatic SB-NETs in acute setting, surgery should be discussed early in the presence of tumor-related symptoms.</p>