Background:Small-bowel neuroendocrine tumours (SBNETs) present heterogeneously, yet the operative and oncologic impact of distinct symptom phenotypes remains uncertain. Methods: A single-centre database (2000-2023) of 108 consecutive SBNET resections was stratified into four phenotypes: obstructive symptoms (n = 54), carcinoid syndrome (22), asymptomatic/incidental (22) and other specific symptoms (9). Baseline biology, operative details and outcomes were compared with Kruskal–Wallis, χ²/Fisher and multi-group log-rank tests (α = 0.05). Results: Operative urgency varied sharply by phenotype. Obstructive cases underwent emergency laparotomy in 50% versus ≤11% in all other groups (p < 0.001). Open surgical approaches were used in 87% of obstructive versus 55–59% elsewhere (p = 0.052). Baseline liver metastases were more common in patients with carcinoid syndrome (50%) and obstructive tumours (20%) compared with 5% if asymptomatic/incidental (p = 0.002). Despite these differences, surgical oncologic quality was uniform: median lymph-node harvest of 10–13 nodes (p = 0.426), R1/R2 margins in ≤13% across groups (p = 0.290), and median length-of-stay of 8 days in every cohort (p = 0.311). Median overall survival (OS) differed significantly by phenotype, with Kaplan–Meier log-rank test demonstrating improvement in OS in the asymptomatic/incidental subgroup compared with the obstructive and carcinoid phenotypes. Multivariable Cox analysis revealed that only the asymptomatic/incidental phenotype remained independently protective (HR 0.42, 95% CI 0.19–0.93, p = 0.032). Conclusions: Symptom phenotype dictates operative urgency and survival but does not compromise technical standards in a specialized unit. These findings support the centralization of SBNET management, ensuring that even emergency presentations receive guideline-concordant lymphadenectomy and oncologic care.