(CNN) — Comedian Joan Rivers lost her life after having an apparently minor elective procedure at a Manhattan medical clinic last week.
The routine surgery was on her throat, according to the New York Fire Department. She apparently suffered cardiac and respiratory arrest during the procedure at Yorkville Endoscopy. She was transferred by ambulance to Mount Sinai Hospital and died on Thursday.
The outpatient clinic is now being investigated by the New York State Department of Health, according to its spokesperson, James O’Hara.
No criminal investigation is underway, according to several New York law enforcement officials. The state health department is investigating whether there was any malpractice by the doctors and their staff, the same officials said.
Rivers’ autopsy was inconclusive, the medical examiner’s office said.
The routine nature of the surgery has left some asking how it could have killed her.
Doctors say just because a surgery is called routine or elective doesn’t necessarily mean it is simple.
“Elective typically just means it is something you can plan ahead of time, as opposed to emergency surgery where you need to get someone in right away,” said Dr. John Sweeney, chairman of the department of surgery at Emory University in Atlanta.
When Sweeney talks to his patients about surgery he explains that there are always risks involved.
There could be complications due to bleeding or infection during the procedure. Or there could be specific risks related to the type of operation.
Endoscopy usually refers to an evaluation of the esophagus or GI tract, according to Dr. Joel Zivot. Zivot is an assistant professor of anesthesiology and surgery at Emory University School of Medicine.
He said sometimes patients will have these procedures so doctors can evaluate their vocal cords.
Endoscopy is normally done under general anesthetic. Operating on the vocal cords is trickier, because a tube that would normally help someone breathe during such a procedure couldn’t go across the vocal cords. To tolerate that kind of evaluation, Zivot said, someone would need to be in a deep unconscious state.
The center has not released the specifics about the kind of procedure Rivers had, so it is unclear if she would have had a simple anesthetic spray on the throat or something where the airway was compromised.
“People have endoscopy safely every day in this country,” Zivot said. “Generally speaking, it’s well tolerated.”
There can be risk with surgery if someone has any kind of underlying health problem.
In the initial surgery consult, Sweeney said he always asks patients: Do they smoke? Do they have diabetes? Do they have heart problems or lung disease?
Essentially, do they have any kind of physical problem that would put them at an increased risk for complications?
“Some doctors will throw in age as a risk, but I would call that ‘chronological age,’ because I have some 51-year-old patients that are physically in much worse shape than someone who is much older,” Sweeney said.
“She is not someone you look at and say ‘that woman looks frail,'” said Dr. Jonathan Flacker.
Flacker, also at Emory, sees a number of older patients in the geriatrics department. Neither he nor Sweeney treated Rivers.
“She was vibrant and engaged and great at intelligent conversation, everything someone would want to be when they are older,” Flacker said.
But he added, older people, no matter how energetic they appear, do have an inherent age-related disadvantage when it comes to surgery.
When people get older they have less of what doctors call repertoire and reserve. That means their older body and brain lose some ability to cope with stress.
“Older people tend to lose their repertoire and their ability to cope with stress through a variety of reasons and not all of them relate to a disease state. They come along with age for everyone,” Flacker said. Surgery of any kind, he said, is a real stress on the body. That’s what makes surgery riskier for older people.