Discussion

This case demonstrates that upper esophageal foreign body removal, despite being the operator’s first such procedure, was completed promptly with the aid of a structured pre-procedural briefing and intraoperative supervision through a video laryngoscope. Although the evidence base for briefing has accumulated largely in the context of routine operating-room surgery, the same principles appear applicable to infrequently performed emergency procedures.

Briefing has been reported to improve learner engagement and educational effectiveness by clarifying learning goals and expected performance while preserving psychological safety [6]. In airway management training, briefing has also been shown to improve learner performance and team communication by defining objectives, assigning roles, and reviewing procedural flow in advance [7]. A recent systematic review of 30 studies on preoperative educational briefings extracted recurrent themes from briefing templates and proposed an evidence-based framework consisting of four categories: Goals, Autonomy, Preparation, and Strategy (the GAPS framework), which together encompass trainee goal setting, the degree of learner independence, case-specific preparation, and operative as well as communication strategy [8]. Implementation of briefings structured around these categories has been associated with improvements in surgical learning and performance outcomes, including goal setting, feedback, and trainee autonomy [8]. Guided by this framework, we structured the pre-procedural briefing around the four GAPS categories: clarification of the procedural goal and learning objectives under Goals; confirmation of the operator’s experience and level of autonomy under Autonomy; sharing of patient information under Preparation; and role assignment under Strategy. Because this was an infrequently performed emergency procedure, we additionally incorporated standard perioperative safety-briefing elements (confirmation of equipment and medications, assessment of the risk of complications, standardized communication, and an emphasis on safety culture), consistent with perioperative team briefing, which has been associated with improved team performance and patient safety [4] (Table 1).

Because the GAPS framework was originally derived from briefings for routine scheduled surgery, its application to an infrequently performed emergency procedure, such as upper esophageal foreign body removal, is not fully established. Nevertheless, addressing each of these four categories during the briefing is likely to support both operator learning and procedural performance, with potential value for education and patient safety.

To our knowledge, no prior report has specifically examined the educational impact of intraoperative instruction through video laryngoscopy during esophageal foreign body removal. However, for tracheal intubation, a technically related procedure that requires similar equipment and anatomic orientation, the educational value of video laryngoscopy has been better established [9]. In novice or less experienced operators, video laryngoscopy has been associated with lower failure rates and shorter intubation times, including in simulation settings [9].

In a recent systematic review and meta-analysis, Gunning et al. reported that video laryngoscopy used for teaching was associated with a higher first-pass success rate than conventional direct laryngoscopy and with improved instructional quality and learner confidence because the operator and instructor could view the same anatomy simultaneously [10]. Use of Macintosh-type video laryngoscopes, in particular, has been associated with higher first-pass success and better learner satisfaction and anatomic understanding [11]. These findings support the role of video laryngoscopy as a useful educational tool in airway training.

Direct removal of an esophageal foreign body under laryngoscopic visualization is performed less frequently than tracheal intubation, and no standard simulation method has been established. In this setting, shared visualization through a video laryngoscope, coupled with real-time instruction, may have contributed to first-attempt success in our case. In addition, infrequently performed procedures are known to impose a substantial cognitive load, which may impair recall of steps and precautions [12]. In the present case, important technical points that differed from routine intubation included securing the endotracheal tube to the left side of the mouth to preserve working space, the position at which the blade tip should be applied, and maneuvers to avoid collision between the Magill forceps and the laryngoscope. These details had been emphasized during the pre-procedural briefing, and repeated real-time guidance during the procedure may also have supported successful removal.

This experience should be interpreted with caution. The operator in this case was already experienced in tracheal intubation, familiar with both the video laryngoscope and Magill forceps, and well-acquainted with the relevant anatomy. This likely allowed focused attention on the procedural differences from ordinary intubation such as endotracheal tube depth and extraction mechanics. The extent to which these findings can be generalized to less experienced operators therefore remains uncertain.

For relatively uncommon procedures, such as upper esophageal foreign body removal, retention and consolidation of technical skills are important. Debriefing after the procedure has been shown to enhance educational outcomes by reinforcing technical and non-technical skills, consolidating knowledge, strengthening teamwork, and identifying points for improvement before the next case [13]. Informed by the clinical debriefing literature [14], we conducted a structured post-procedural debriefing covering the following domains, as summarized in Table 2: the conduct of the procedure, technical and non-technical performance, teamwork and communication, complications or safety concerns, improvement measures, action goals for future cases, preservation of psychological safety, and participation by all team members.

Debriefing item | Specific example in the present case
Review of the procedure | The physicians involved in the procedure reviewed the use of the Magill forceps.
Assessment of technical and non-technical skills | The team evaluated how closely the procedure had followed the algorithm established during the pre-procedural briefing.
Analysis of teamwork and communication | The team analyzed whether real-time instruction from the supervising physician had been useful.
Identification of complications and safety concerns | The team discussed the possibility of pushing the coin farther distally and the appropriate timing for aborting the procedure.
Proposal of improvement measures | No specific improvement measures were proposed because the procedure had been completed smoothly.
Setting specific action goals for the next case | The team reviewed the procedural steps and set a goal of using the same instructional approach if a similar case were encountered in the future.
Maintenance of psychological safety | The session began with a brief defusing period, followed by open discussion of participants’ impressions of the procedure; the supervising physician then summarized the strengths and areas for improvement.
Sharing opinions among all participants | The team reviewed the procedural video together and shared their perspectives.

Although simulation and repeated practice remain important for long-term skill retention, appropriate debriefing after an actual clinical case may further strengthen learning [15]. Debriefing has also been associated with improvement in clinical skills, diagnostic reasoning, motivation for learning, and awareness of teamwork [16]. In addition, in operating rooms and emergency care settings, the use of both briefing and debriefing has been associated with better team communication, fewer procedural interruptions or delays, and a stronger culture of patient safety [17]. Our experience supports the importance of an explicit team plan before undertaking such procedures. Ensuring the availability of backup support from otolaryngology, gastroenterology, or surgery is also advisable in case laryngoscopic removal is unsuccessful. Furthermore, no objective educational outcomes, such as skill assessment, procedural time, learner confidence scores, or simulation-based evaluation, were measured in this case; the educational benefits described here therefore remain observational.