Well-differentiated small bowel neuroendocrine tumors, while comparatively indolent malignancies, are frequently metastatic at the time of presentation. Whether to resect the primary small bowel tumor(s) and associated mesenteric lymphadenopathy in the setting of unresectable distant disease remains controversial. Multiple retrospective studies have found symptomatic and survival benefit to primary tumor resection, but these studies have been criticized for their selection bias. The matter is complicated by the fact that there are increasingly effective systemic and liver-directed therapies that control symptoms and prolong survival. Herein, we review the evidence for and against primary tumor resection and provide recommendations for when to operate and why.