Story highlights Joan Rivers suffered complications during minor elective surgery

Any kind of surgery comes with risk

Age can be a complicating factor for surgery; Rivers was 81

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 under way, 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.

Photos: Joan Rivers through the years Photos: Joan Rivers through the years Comedian Joan Rivers died September 4, 2014, a week after suffering cardiac arrest during a medical procedure, her daughter said. She was 81. Click through the gallery to look back at her career. Hide Caption 1 of 19 Photos: Joan Rivers through the years Rivers' big break came in an appearance on Johnny Carson's "Tonight Show" in 1965. It was the beginning of a relationship that would include dozens of appearances as guest and guest host. Hide Caption 2 of 19 Photos: Joan Rivers through the years Rivers followed her Carson breakthrough with appearances on talk and variety shows. Ed Sullivan had her as a guest in 1966. Hide Caption 3 of 19 Photos: Joan Rivers through the years Rivers hit a peak in the 1980s, headlining in Las Vegas and becoming a regular guest host on the "Tonight Show." Hide Caption 4 of 19 Photos: Joan Rivers through the years Rivers is famed for her quick wit, which she often uses against herself. Hide Caption 5 of 19 Photos: Joan Rivers through the years Rivers later hosted talk shows of her own. Here, she chats with Dolly Parton. Hide Caption 6 of 19 Photos: Joan Rivers through the years She starred on the daytime "Joan Rivers Show," for which she won a Daytime Emmy, for five seasons, from 1989-1994. Here, she poses with her dog, Spike. Hide Caption 7 of 19 Photos: Joan Rivers through the years Rivers wanted to be an actress when she was young, and she fulfilled that goal after her success as a comedian -- though sometimes playing herself, as she did on "Nip/Tuck," with Julian McMahon, left, and Dylan Walsh. Hide Caption 8 of 19 Photos: Joan Rivers through the years Rivers and her daughter, Melissa, have been regulars on awards show red carpets, critiquing celebrity fashion with lines both generous and cutting. Hide Caption 9 of 19 Photos: Joan Rivers through the years Rivers talks with Tim McGraw and his wife, Faith Hill, at the Grammys in 2005. Hide Caption 10 of 19 Photos: Joan Rivers through the years Rivers with Tina O'Brien at the British Academy Television Awards in 2007. Hide Caption 11 of 19 Photos: Joan Rivers through the years Rivers was a star among comedians, admired for her longevity and wit. She attended the Mark Twain Prize ceremony in 2008. The honor that year went to the late George Carlin. Hide Caption 12 of 19 Photos: Joan Rivers through the years Kathy Griffin is one of many comedians who can cite Rivers as an influence. Like Rivers, Griffin is known for mocking celebrities at various events. Here, she and Rivers share a stage during a Rivers roast in 2009. Hide Caption 13 of 19 Photos: Joan Rivers through the years Rivers proved herself to be quite the savvy businessperson by winning a season of Donald Trump's "Celebrity Apprentice." Trump and his wife, Melania, join Rivers at the season finale in 2009. Hide Caption 14 of 19 Photos: Joan Rivers through the years Katie Finneran and Rivers attend the Broadway opening after-party of "Promises, Promises" at the Plaza Hotel in New York in 2010. Hide Caption 15 of 19 Photos: Joan Rivers through the years Rivers, a fashion lover, attends the LensCrafters' reveal of Sunglass Fashion Crimes in 2011. Hide Caption 16 of 19 Photos: Joan Rivers through the years In February 2013, she attended the Dennis Basso Fall 2013 fashion show. Alongside her, from left, are Martha Stewart, Star Jones and Kelly Bensimon. Hide Caption 17 of 19 Photos: Joan Rivers through the years After a falling-out with Johnny Carson, Rivers didn't return to the "Tonight Show" until earlier this year, when Jimmy Fallon took over as host. She was a guest on Fallon's show on February 17. Hide Caption 18 of 19 Photos: Joan Rivers through the years Rivers officiates the wedding of William "Jed" Ryan, left, and Joseph Aiello at the Plaza Athenee on August 15 in New York. Hide Caption 19 of 19

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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.

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"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.