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Abstract Background Diaphragmatic hernia is frequent among the elderly and is usually associated with mild chronic digestive and respiratory symptoms. Case presentation An elderly post-esophagectomy male patient, in the early postoperative period of cardiac surgery, presented with acute respiratory distress. An emergent surgery was performed to reduce a giant diaphragmatic herniation. Conclusions An acute transhiatal herniation can cause serious respiratory impairment; surgical repair should be considered in select patients of cardiac surgery.